Lockhart River on Australian Story

[OZBUSDRIVER]

Missed it! Anyone get to watch to see which way it was heading. Tail end says we are going to get a more independant ATSB as well as an oversight commitee on CASA

[mohikan]

Nice that they slandered the dead PIC. He cant sue - typical gutless journos.

Whilst I sympathise with the family the bottom line is that they have missed the point - that passengers on small commuter airlines are not prepared to pay the airfares required to support safety at the 'big airline' RPT level.

I thought the sons final comments on the mental condition of the father were interesting

[Pro777]

Viewable online at ABC iView (http://www.abc.net.au/tv/iview/). Search for Australian Story. You'll need a decent broadband connection though.

[Old Fella]

Mohikan You obviously have no concept of the commuter airline ops in Australia. The route on which the Lockhart River accident occured would not generate enough traffic for a bigger airline and an operator could probably charge whatever fares they wanted. Not too many options for long distance travel on the Cape.

[mohikan]

Fella.

You make my point for me - pax arnt prepared to pay for safety and cry sad when accidents / incidents happen.

I have flown commuter BTW. Understand where your coming from

[Jabawocky]

I see that Australia's cr@piest aerodrome ...well its not really, but according to some, featured in the end, not sure about the relevence of that but it is local to where Sally's family live.

I am not sure I share Shanes view that the pilot is not the one they blame. Sure there must have been a systemic problems in the company and CASA for not overseeing that organisation, but really.....had he not flown a crazy approach, and the data clearly shows he did, and he had a name for that kind of behaviour, the accident would not have happened.

I feel its covering up some of the facts for the sake of a deceased person who actulally could have prevented it from happening in the first place. Sure, Transair and CASA are very much at fault here, but the PIC is the Pilot IN COMMAND after all.

Otherwise a good programme on a family wanting to see something worthwhile come out of such a tragedy.

J

PS Shane I know you read these pages. :ok:

[mohikan]

Here we go again.

"He had a name for that sort of behaviour"

Is the sort of statement that if the Captain were alive would see you in court and sued.

Easy to sink the slipper into those who cant defend themselves.

Moron.

[Hempy]

Jaba,
I'm not sure you meant to contradict yourself, but you did.
I am not sure I share Shanes view that the pilot is not the one they blameSure, Transair and CASA are very much at fault hereSo, whose fault was it?

Shane,

Fight the good fight, and congratulations on your efforts so far. Calling on CASA to actually DO THEIR JOB is something that should have been done in this country years ago. Hopefully your efforts will not just improve the lot in FNQ, but Australia wide. Now if only they had a good look at the ANSP....

[Casper]

Calling on CASA to actually DO THEIR JOB is something that should have been done in this country years ago.
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I have read ALL the reports of all the investigations in regard to this operator.

Believe it or not, the CASA audits prior to the crash were extensive with four inspectors assigned to the audit immediately prior to the accident. En-route surveillance was conducted on EVERY RPT sector operated by Transair in Qld (including Bamaga and Lockhart River) and its NSW offshoot, Big Skies.

No amount of surveillance, however, would have prevented the accident as described in the ATSB report - the (deliberate) unstable approach.

What did emerge after the crash was the fact that the accident PIC had testified at a previous coronial that a "shooting hole approach" was necessary in order to get visual in certain circumstances. The fact that the PIC of an RPT operation admitted such practices should have been a very large concern for all who were aware of such an admission. Warning bells should have been activated. It has been suggested that a government agency (not CASA) was present at that coronial and did not pass on the intelligence.

Failure to forward such intelligence, if true, is every bit a threat to aviation safety as conducting the actual "shooting hole approach."

[hoboe]

For those that missed it, it is on again tonight on Abc2.

Australian Story - ABC2 Television Guide (http://www.abc.net.au/tv/guide/abc2/200903/programs/NC0856Q022D3032009T200000.htm)

[Jabawocky]

Hempy...... ALL THREE of them. For some reason Shane seemed to take the heat off the PIC. Should I re-word that better, the PIC was at fault and CASA/Transair were to blame for him being able to be at fault. In a more simple way, all three are in it together.

mohikan...... I understand your feeling that way, maybe he was a mate of yours, however the factual data showed exactly what kind of approach he flew. Plenty of others who knew him made that claim, on here and in the media and quite likely at the inquiry.

I and many others have never tried to sink the boot in just because he is deceased. I bet we all feel for his family too. The F/O's family, part of my families school community were close enough to this to feel it too mate. Tell me the data was completely wrong and then prove it, we all may change our minds.

If I were on the flight, and we somehow missed the the treetops and landed, I would have damn well said it to his face! If the slipper fits mate........

As for here we go again, the ABC started the discussion again and you posted at 19.53........ :ugh:

I am sorry this upsets you to have critical comment of the PIC, but the world is full of aviation accidents where the PIC was very much the focus of attention, do you want to deny all of those too?

We can not do anything now to change the PIC, but CASA and operators can change, and every pilot can change just a little bit too to help ensure every flight is a safe one, not just one where they arrived in one piece.

J

PS..... Thanks Casper, I knew I had read something along that line before, but I do not have a library full on the matter!

[Merlins Magic]

that a "shooting hole approach" was necessary in order to get visual in certain circumstances.:ugh:

Statements like that really give me the sh!ts. Airmanship says that if you don't get visual either try again or divert elsewhere. Yes it may disrupt a few peoples lives but at least they will still have a life to disrupt.

The fact is, this accident did happen. Let us all learn from this, and every other accident, to see that it doesn't happen again.

[neville_nobody]

Something that wasn't addressed in the show was how inconsistent CASA is across the country. They hammer some operators for all sorts of minor non issues yet don't take action on others. From what I've seen if you are game enough to challenge CASA in court they will tend to back off.

However I wasn't impressed by the father's call for the old 'world's best practice' in that senate committee meeting. That is not going to solve anything in this country.

[Torres]

mohikan. Since when was there a legal correlation between the fare paid by a pasenger and the standard of safety they receive?

That air route was a monopoly air route with a high seat/mile air fare.

Casper. If the operator audit and surveillance by CASA was as you suggest, how would you account for an FO (who may have been conducting the approach) not rated for that type of approach?

[Mach E Avelli]

Torres, a CASA audit or surveillance can only pick up what they see on the day, or are shown in the records. For example, in my most recent job, I was one of only two Captains on the fleet with a current RNAV approach approval. None of the F/Os had it. That did not preclude us from flying 'practice' RNAV approaches in VMC. But when the wx was IMC, to stay legal we had to fly whatever approach both of us were approved for - usually NDB or ILS at our particular destinations.
But suppose we had illegally done a RNAV approach but shown it in the aircraft trip logs and our own logbooks as NDB. How could CASA know unless they were there on the day and witnessed it or another operator knew and dobbed the crew in?
CASA certainly had a part to play in the Lockhart disaster, but on the day the only persons in a position to prevent what happened were the two pilots. It has been established that the unfortunate F/O was not properly trained for what they attempted, so he is far less culpable than the PIC but nevertheless he obviously was there for the ride and we must presume either agreed it was a reasonable thing to be doing - or was not able to object, perhaps for fear of his job. CASA can't dictate RNAV endorsements for all pilots unless RNAV is mandatory for a particular operation. Any more than they can stop pilots flying under the influence of drugs, unless they test every pilot before every flight.
Other major factors were the approach plate design and aircraft equipment - CASA again. But the guy who drilled it into the hill was ultimately responsible and we as a pilot community have to accept that, as unpleasant as it may be for the deceased pilot's family.

[Hempy]

Casper, as you know, there is a long straw between conducting an audit and acting on its results. What were the results of said audits? What procedures etc were changed? Did CASA supervise these, or monitor their acceptance? CASA has been doing its job alright, only half-arsed and non-committal. I could tell some stories believe me, but my employer monitors these pages....

[Casper]

Hempy,

I was advised that there were no outstanding issues in regard to actual flying operations. I was also advised that there were several issues in regard to airworthiness.

At the end of the day, however, airworthiness issues and the fact that not all pilots had completed HR courses (not required legally at the time but only by the operator's manual) did not contribute to the crash.
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If the operator audit and surveillance by CASA was as you suggest, how would you account for an FO (who may have been conducting the approach) not rated for that type of approach?
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Torres,

From the ATSB report, it is unlikely that the FO was conducting the approach as he had been operating the radio. Notwithstanding that scenario, it was not appropriate for an RNAV approach to be conducted without both pilots being endorsed.

From an operational aspect, however, what would you prefer - NDB or a runway oriented approach?

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As mentioned elsewhere in this thread, an audit is a snapshot and the fact that an FO was not RNAV/GNSS rated may be easily missed.

Most pilots seem to agree that distances on RNAV charts should be to the MA point or runway threshold and NOT simply to the next waypoint.
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Irrespective of all the above, the sad bottom line is that the approach was far from stable and altitudes were busted, thereby placing all on board in mortal danger. THAT is what should be addressed and avoided.

[snoop doggy dog]

Facts are that CASA had more than enough information on Trans@ir to warrant an unbiased audit on this company. Forget the confidential hotline, ex-employees went to various CAS@ offices and gave them damning information on Transair. It all had to be sent back to the Brisbane office to be followed up. Surprise surprise, all boxes ticked and the company given a clean bill of health :ugh: This all way before the Lockart River disaster. That's right, people who could have been key witnesses (with evidence) against CAS@ and Trans@ir at the inquest, weren't called upon

The owner of Trans@ir was mates with the CAS@ office that looked after him. They looked the other way and allowed all to continue. The audits were a joke at best

The ABC know this and this is why they keep running the storey to make people accountable for what they did and didn't do. They have interviewed many ex-employees and taken an account of their times there.

Many people could have stopped this, including a Minister at the time whom had a full account of what was happening prior and swept it under the table. He later resigned as Deputy PM (due to health BS) when he knew he could get in the sh!t. He helped this company in various ways, including free landing charges at a particular aerodrome in NSW.

Too many people covering their ar$es high up in the government (and everywhere else) at the time for anything to really come of this. :ugh:

CAS@ are like a bull with no Horns and no Balls.. They just sit around and bull$hit all day :ok:

[BondiBoy]

Spot on Snoopy. :ok:
The program should be made compulsory viewing for all CASA staff (maybe during their induction)....especially the Melbourne Airline Office.

[Frank Burden]

I like the contrast between posts made by people such as Mach E Avelli, Jabawocky and Casper compared with Mohikan and Snoop Doggy Dog.

The pilot in command has the ultimate responsibility to operate an aircraft safely. However, in Australia we always hear that the pilot of an aircraft that is involved in a major accident or incident was the epitomy of the safest pilot that has ever flown an aircraft.

An audit by a regulator can only do so much. The safety equation relies on everyone involved in aircraft operations meeting their responsibilities.

The information garnered for a television show is very much different to the burden of proof required in a court of law.

Snoop Doggy Dog and some others here, check your factual caution warning light. It's on.:=

[Hempy]

JetA_OK

On your suggestion I did just that.

Those poor people had a terrifying last few mins of their life, and the person responsible for their safety and care while onboard the aircraft was responsible.


Ever decided to get a job as a journo? What rubbish. Maximum rate of descent over the actual approach was 2400 fpm. Because of the lack of CVR over the final stages, the only indication that anyone on board may have known their vnav was wrong was the descent rate decreasing from 2400 to 1200 fpm during the last 10 seconds of the flight. I would suggest that other than the normal nerves of paxing in a 'small' aircraft in IMC, the poor buggers never knew what hit them. And that's a good thing.

[Mach E Avelli]

The culture at CASA at the time was interesting. Flying Operations Inspectors assigned to airline operations had for some years been in the invidious position of being expected to pass judgement on their peers but with no 'real' flying officially allowed to maintain any credibility or proficiency of their own. There was a limited budget for the airline guys to supposedly maintain proficiency on simulators, but even that was a joke. Most sim sessions that I attended were more like an all-day jolly away from the office playing video-arcade games. There was no structure to the programme whatsoever. Little wonder, given that the guys running the sim were also CASA people with no recent experience and in some cases no actual type experience.
The Team Leader had spivved a couple of endorsements at taxpayers' expense and had a bit of a cosy arrangement going with the operator so that he could get Metro time - all in the line of duty of course. In that culture it was not surprising that anyone in a position to get some free flying would take advantage of every opportunity.
A couple of the other FOIs in the Brisbane office were a standing joke in the industry and within the CASA office itself. One even had a standard audit format that he regurgitated with each new audit, just changing the name of the auditee and minimal other detail to make it look like he was busy.
There were also a few very professional and dedicated FOIs in that office.
Not surprisingly, most have moved on.
CASA would appear to have declined even further since then. At least even the lazy FOIs did have prior flying experience and could pick up on things like overloading, underfuelling etc. Now it's gone totally touchy-feely with all this crap about threat and error management, having a safety management system with huge committees meeting every other week, lots of pie diagrams, statistics and charts etc. Auditors look at manuals and they go ape-**** if a page is missing or an amendment is not up to date or a pilot went 10 minutes over the duty limit without going into intensive care, or a flight attendant tripped on the carpet and didn't get counselling.
As for Airworthiness - when was the last time an AWI got into a wing-box with a mirror and a flashlight? All they seem to do is look at records and part numbers and woe betide if a signature or licence stamp is missing on a turnaround check or someone reset a circuit breaker without a two-page write up.
Many CASA Auditors these days don't even have an aviation background - how does that work?
I have an aviation lead auditor qualification and have also worked for more than one dodgy operation. So I know how easy it is for a smart operator to hide stuff. Only someone who has been in the industry long enough to have operated in the arena that is being overseen, broken a few rules in his time, and seen other creative ways of breaking them, can do this job to the thorough extent that is needed.
Sadly CASA doesn't provide the motivation for old-hand pilots and engineers, so it is increasingly coming uner the control of the psycho-babble brigade. Less scrupulous chief pilots and maintenance controllers will run right over these guys.

[56P]

Now it's gone totally touchy-feely with all this crap about threat and error management, having a safety management system with huge committees meeting every other week, lots of pie diagrams, statistics and charts etc. Auditors look at manuals and they go ape-**** if a page is missing or an amendment is not up to date or a pilot went 10 minutes over the duty limit without going into intensive care, or a flight attendant tripped on the carpet and didn't get counselling.
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Welcome to the "Byron in ATI Land" Legacy!

[Fidoda]

Yep please JetA_OK none of us who lost our loved ones really want to think that the last few moments of their lives were terrifying. We already live with the nightmares.
Thanks Hempy, I like to think that none of them knew what hit them too.

Shane is trying to keep the fight alive and hey maybe the world needs more people like him!

Fiona

[TyreCreep]

Many CASA Auditors these days don't even have an aviation background - how does that work?
I have an aviation lead auditor qualification and have also worked for more than one dodgy operation. So I know how easy it is for a smart operator to hide stuff.

In fact, they don't even need to be that smart to hide stuff. CASA audits are very superficial.

I find the whole thing quite alarming, to be honest.

[blackhand]

Sense of deja vu over this.
Those that were around will remember the Seaview inquiry.
Same accusations of a CAA operative in bed with the operator.
Anything to take the blame off the PIC.
A good man lost his job, lost his marriage and damn near lost his soul because of A-sholes like some here talking about that of which they have no knowledge.

Blackhand

[grip-pipe]

The crew of the Metro have already paid the ultimate price for their efforts, they lost their lives, sad and unforgivable part is they took 13 trusting fare paying passengers with them. The facts are they took a reasonably serviceable aircraft and flew it into a hill, why? because they thought it would not happen to them! Complacency and arrogance will eventually get you whether your the operating crew or the operator it is only a matter of time and as history has shown yet again, the operator very rarely if ever survives the outcome.

If you do not regard the people up the back as more important than you then you have no place in the business and your not a professional. It is your job to do that, it is the company's job to give the equipment and training to keep you doing your job and it is the regulatory authorities job to see that your all doing your job the way you said you would. I don't see any evidence that anybody did their job in this tragedy.

[Kangaroo Court]

Yup! I agree. There have been too many people selling "airline" tickets to unsuspecting people with ticket jackets of wide bodies printed on them, only to find they are flying in something like a spent Metro circa '83.

Also the flying training in civvie street during the hiring frenzy went to sh!t.

[FlexibleResponse]

Aviation training is very much a pass-down experience type of event in which the junior flyer learns from the guidance and the teaching of his senior.

With this thought in mind, one is drawn to the conclusion that it is unlikely that the "shooting hole approach" reportedly quoted by the late PIC was some invention of his own.

One might be excused from surmising from the PIC's reported comments that this type of approach was condoned by the operator of the Airline in question.

Perhaps the real instigator of the events leading to this tragic accident is still lurking out there and is now awaiting a new alignment of the holes in the Swiss cheese for the next disaster?

The accident was a terrible loss to all those involved, But, if we fail to learn from the mistakes that were resposible for this event, then we will be doomed to repeat them.

[grip-pipe]

Never really taken to the shooting the hole explanation. LHR is an evil place at the best of times with the strip in a funnel valley with constant strong SE winds and high hills and a mountain at the end. Given it away many times there simply because of the sheer and turbulence in an approach from the west will push you up and down really hard (Seen +/-1000 fpm in the holding pattern on a bad day). Think they caught caught at LHR in an unstable approach at a point on the GPSNPA where the minima is literally that 300ft. The wind is always across the range at that point pushing a stream of eddies and lee turbulence at that critical point if they encountered even isolated sheer at the speed they were travelling and uncontrolled ROD it was game over! Sensible course is to take the NDB or the let down over water to the east at about 5-10 nm to 1500ft any day to the GPS NPA as currently published. They haven't produced one from the east because in my view with the prevailing winds it would always result in a circling approach which would be an ask in anything above CAT B.

[Joker 10]

Grip Pipe, A rational statement which underlines the difficulty in self designed approach procedures.

Local knowledge is a powerful tool but misuse of that knowledge will end up in grief almost always if one strays onto the dark side and "goes it alone".

[beaver_rotate]

Grip-Pipe:

http://www.airservices.gov.au/publications/current/dap/LHRGN02-116.pdf

Done it many a time in Dash8. I would do this AND CIRCLE over the western RNAV anyday.

Your right about the Western RNAV. Done it in VMC, 300' RADALT is rather tight coming in over Iron Range at the FAF.

BR

[FlexibleResponse]

As JetA OK suggested, I went to the ATSB site and watched the animation. It was a very sobering experience and any professional airline pilot viewing that animation would question how it was possible and why?

The ATSB report on the accident, which documents in painful detail, the lack of adherence to standard procedures, the incompetant execution of operational procedures and other errors of the AOC holder and the ineffective oversight by the Aviation Regulator are so shocking, that one wonders if they aren't referring instead to some impoverished African nation rather than to Australia.

[Barry Bernoulli]

Hempy,

Am I missing something here? Are you suggesting that 2400fpm is an acceptable rate of descent at any point on an approach? Shouldn't the standard be about 600-650fpm? I would have thought that even 1200fpm would be unacceptable after the IF.

[Casper]

and the ineffective oversight by the Aviation Regulator are so shocking, that one wonders if they aren't referring instead to some impoverished African nation rather than to Australia.
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I have read the transcripts from the Coroner's Inquest and, from both flight operations and airworthiness perspectives, the oversight by the regulator was, in fact, most comprehensive. En-route surveillance was conducted on EVERY RPT sector (BAM & LHR included) in an audit immediately prior to the accident.

No number of such inspections, however, could prevent such a "shooting hole approach" induced crash if the PIC was that way inclined - and evidence from a previous coronial suggests that he was.

What is most disturbing is that this evidence by the PIC at this previous coronial was not reported to anyone - his employer, the regulator or anyone! The ATSB reportedly were in attendance at this coronial and did not forward this intelligence to anyone.

Not reporting this intelligence is, I believe, just as big a threat to aviation safety as the PIC actually conducting such "shooting hole approaches."

As has been stated previously, the FDR data says it all. I believe that, in this case, the coroner delivered a correct finding.

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Am I missing something here? Are you suggesting that 2400fpm is an acceptable rate of descent at any point on an approach? Shouldn't the standard be about 600-650fpm? I would have thought that even 1200fpm would be unacceptable after the IF.
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Absolutely correct. Such descent rates in no way constitute a stabilised approach and a MA should have been conducted. "Cowboy flying" reflects poorly on the reputation of every professional pilot.

[Hempy]

Hempy,

Am I missing something here? Are you suggesting that 2400fpm is an acceptable rate of descent at any point on an approach? Shouldn't the standard be about 600-650fpm? I would have thought that even 1200fpm would be unacceptable after the IF

Barry,

Yes, I think you are missing something. My reply was to JetA_OK, who stated "Those poor people had a terrifying last few mins of their life". I'm not suggesting anywhere that the pilots were flying the correct approach, the proper way, or as you say 'acceptable'...obviously they weren't or they wouldn't have plowed into a hill. I AM suggesting that 2400 fpm, in my experience, certainly isn't "terrifying", nor do I think anyone on that aircraft believed their life was in mortal danger (except, as I said, perhaps by the pilots in the last ten seconds before impact). It's OK to apportion blame based on the evidence, but to insinuate how the pax on the aircraft were feeling? please...