Mount Hotham crash Coroners Inquest

[TunaBum]

The Geelong Advertiser (http://www.geelongadvertiser.com.au/article/2009/04/30/66881_news_pf.html)


An investigation following the crash revealed a bolt that connected the throttle was missing.


OK then - that explains it !!!


Mr Macgillivray said the pilot did not breach aviation regulations when he flew from Essendon to Mount Hotham despite the weather conditions, which he described as "extreme".
The inquest was this week told aviation authorities monitored Mr Lee's flying practices for several years and he had received reprimands for flying low at night and into controlled airspaces.
Mr Macgillivray said the infringements were more "carelessness" than an actual piloting problem.
"I don't see safety breaches contributed to the accident," he said.
Mr Macgillivray said he believed the engine had cut out.
"The propeller was not being driven by any significant power at the time of impact," he said.


Fair enough.


TB :rolleyes:

[Lookleft]

Not sure where he gets his information from but he's wrong. The engine was producing power and lots of it at the time of impact. Just re-read the report.

[Diatryma]

Yes but the ATSB has been wrong before? Perhaps they had their minds made up before they investigated (based on RL's history), and didn't do a thorough job? It's possible.

Di :O

[Checklist Charlie]

Mr Macgillivray saidWho is this Mr Macgillivray, not from West Sale by any chance?

Di, your thinking is way off the mark. Controversial yes, valid, no.

[goddamit]

either way the moral of this story is to keep your operation squeaky clean. At least then if sh!t happens you will be given the benefit of the doubt & die honorably.

[Diatryma]

Di, your thinking is way off the mark. Controversial yes, valid, no.


Thanks CC. So you reckon the ATSB are perfect and it not at all possible that they stuffed this up?

Sound like they left a fair bit of stuff up on the hill.

Di :cool:

[porch monkey]

Maybe they did, maybe they didn't. RL did, and should never have been in that position, in that aircraft, on that day.

[Checklist Charlie]

Di, whether I reckon the ATSB is or is not perfect is irrelevant. What is relevant is that the ATSB procedures be robust enough to uncover any errors or irregularities during the normal course of any investigation and that includes any subsequent review. Yes, there have been slipups in the past, hopefully the procedures will ensure there won't be any in the future.

As for 'leaving a fair bit of stuff up on the hill", unless the 'stuff' is evidence and is required to be 'stored' as such, anything else belongs to the insurance company or the owner and it is their responsibility to clean up their 'mess'.

[Diatryma]

CC

Thanks for your feedback.

I agree - your opinion is irrelevant. So is mine. So what?

What is relevant is that there is not much confidence around the place that the ATSB can be relied on to get it right often enough.

I just find it a bit inconsistant what they left on the hill compared with other accidents which have occurred. The owner and insurer had to get it down years later.

Yes lets all "hope" the "procedures" are OK now and everyone can rest assured like you rather than rest in peace like others. I'm not holding my breath. The Govt need to get serious about funding and then we may get some better safety outcomes.

Di :yuk:

[Lookleft]

Di- You say the ATSB has been wrong before, I would be interested in your examples of where they were wrong. When the final report was released on this accident the pilot's wife and a lawyer went very public with "new information" that proved that the investigation had got it wrong. The ATSB then released a supplementary report which backed up the original analysis that the pilot engaged in risky behaviour and had the radar plots to prove it. As the original investigation proved that the engines were delivering power at the time of impact there was no need to take any wreckage back to Canberra for analysis. It is standard practice that after the investigation that the wreckage is then the responsibility of the owner which is usually the insurance company. Who owns a car wreck after the insurance has been paid?

[Diatryma]

The two most obvious examples are the Whyalla Airlines crash and the Central Air "Ghost Flight". I'm sure there are others less publicised.

It is obvious that the pilot engaged in risky behaviour - as it seems was his want. This does not mean that there were not other possible causes and contributing factors. The ATSB should be thoroughly investigating every serious accident such as this one to find out all the causes. The relatives of the deceased passengers deserve that much. That's all I'm saying.

On your insurance comments - if you get drunk and write off your car, I'm sure you will find the insurer will not to be too interested in what you do with the remains of your car.

Di ;)

[Checklist Charlie]

Di.

The ATSB does NOT clean up an accident site. That is the responsibility of the owner, their delegate being the insurance company or some other delegate of the estate.

So as you say "Sound like they left a fair bit of stuff up on the hill" refers to the owner of the remains of the aircraft in question.

Your comment regarding your car, remains exactly that, YOUR car, your mess on the side of a hill. All the same:ugh:

[Diatryma]

CC,

Oh for crying out loud.

I have not said the ATSB should clean up the site. I am simply saying they should take what they need to do a proper investigation.

I know what they left behind - and in my opinion they should have taken much more with them and conducted a more thorough investigation.

Di OUT!
:}

[Checklist Charlie]

Oh dear Di,

So you reckon the ATSB are perfect and it not at all possible that they stuffed this up?

Sound like they left a fair bit of stuff up on the hill.

So who is the they you are refering to?

And:

You say
in my opinion they should have taken much more with them and conducted a more thorough investigation



However you earlier admitted,
your opinion is irrelevant. So is mine. So what

You said it.:ok:

You appear to believe you know better than those involved at the ATSB. I'll tell you what, rather than prattling on here on PPRuNe, how about you take it up with the Bureau and give them the benefit of you knowledge.

Please.:D

[yowieII]

Isn't there still a significant amount of Westwind still on the side of a hill just near ASP?:hmm:

[Lookleft]

Di I am genuinly interested in what you think they should have taken from the site that would have given them a different result. Don't forget that if you were up there well after the investigation any evidence would have been less credible than when the ATSB were up there. If you are referring to the prop hubs I think the supplementary report dealt with that. The prop hubs were the subject of speculation by John Eacott who went up there after the snow melted. He stated on pprune that in his opinion the blades were feathered but the blades had actually separated from the hub so he was basing his opinion on tainted evidence.

CC-At the end of the day we are all just prattling on pprune so why don't you play the ball and not the man.

[Checklist Charlie]

Looki, I am 'playing" what he/she/it says. That is enough, I have no interest in the personae of he/she/it what so ever.:ok:

[Diatryma]

CC - I thought what I said was reasonably simple to comprehend, but anyway....... you have a good day.

Thanks for your support Lookleft - LOL.

Yes I am talking about the prop hubs, blades and the like - and perhaps the exhaust manifolds.

if you were up there well after the investigation any evidence would have been less credible than when the ATSB were up there

- exactly.

I am genuinly interested in what you think they should have taken from the site that would have given them a different result

I'm not saying the result WOULD have been different. My point is we will never know, and that they should have taken more away with them rather than leaving it to the pilots loved ones and/ or JE to do what they could down the track... well after the event.

I don't think that's being overly controversial, however I sincerely apologise in advance if there is anything that I have said which causes offence....!

Di :sad:

(ps: :O)

[VH-MLE]

Diatryma,

Just out of interest, where do you think the ATSB got that investigation wrong?

VH-MLE

[John Eacott]

The prop hubs were the subject of speculation by John Eacott who went up there after the snow melted. He stated on PPRuNe that in his opinion the blades were feathered but the blades had actually separated from the hub so he was basing his opinion on tainted evidence.

I have searched for the original thread on the crash, but can't find it to confirm what I actually posted :(

However, within reason, I'm sure that I made the following points:

I was there at the time of the crash (before the blizzard arrived at Hotham), and visited the site shortly after, with snow still deep on the ground. I also went on the 26th July 2005 when the snow started to melt, revealing stuff that was missed during the investigation. After the ski season, I lifted one engine from the site by helicopter, for further investigation.

My photos of the wreck (which were posted previously, taken on the 26th July) show the props and engines. All the props are/were still attached to the hubs: none broke off. One engine has the props bent from the root, whilst the other has two virtually undamaged props and one slightly bent.

I'm overseas at the moment, but I'll check further when I get home.

[Diatryma]

VH-MLE,

If I recall correctly, the WA Coroner lambasted the ATSB and its investigation of the accident saying that they failed to properly obtain evidence because they did not order full toxicology reports on the bodies of the victims until more than a year after the accident. He said whilst it was clear all of the plane's occupants were either dead or incapacitated for most of the flight, it was impossible to determine what had caused their incapacitation.

Di

[Diatryma]

John,

If I recall you said your photo's ".. show clearly that the RH engine had feathered props, and was stopped before the crash. The ATSB seem to have made little effort to fully investigate the scene, only viewing it whilst there was 2-3 foot of snow on the ground......."

Di :ok:

[Ogsplash]

I was involved in the report writing of the Ghost Flight and had to face the WA Coroner on behalf of the ATSB. All I will say is that considering the process there. I would not take notice of much of what was said. My experience with coronial courts are that they are places where lawyers go fishing and look to see where litigation can be pursued. Coroners have a responsibility to keep things on track but some appear to follow their own agendas.

[Diatryma]

Ogsplash,

That's all good - but shouldn't the ATSB have arranged tox on the victims initially to confirm their theory re depressurisation? Why wait so long? It gives the impression that they had made their mind up already?

Di

[Ogsplash]

Hi 'D', there are some severe limitations in toxicology and even post-mortems when it comes to determining what may or may not have caused incapacitation. I can't recall all the specifics as the investigation file was quite large and I can't honestly answer that one without going through the file.

I do know that one of the first considerations was fumes/DG but it was discounted because there was no evidence in the wreckage (you know, tins or bottles or anything). Also, the problem manifested itself very early in the flight. The ATSB spent a lot of time and resources on that investigation (but I will always admit that an investigation - any investigation - there's always something that could have been done differently but with this one, there was nothing to hint and in the end, the ATSB report said basically on the balance of probabilities, here's what happened).

So there was no pre-determination of a cause at all...indeed everyone was scratching their heads. When you don't have recorders on the aircraft, it regularly comes down to a balance of probability or admitting, we haven't a clue as to what happened. Figuring what happened before the accident and what happened as a result of an accident can be an art unto itself.

Coroners' Courts are interesting animals and what happened in Perth was one reason I left the ATSB, the agressive nature of those involved was startling, there were even threats to throw me in jail because I followed the law!

...it was one thing to do investigations to meet the ATSB's legislative and regulatory requirements, it was another to try and keep state authorities happy as well when in fact the ATSB had no responsibility to the Coroner. If the Coroners don't want to accept these reports, they are quite at liberty to conduct their own investigations. The police can have access to all the evidence once the ATSB has finished with it. The ATSB just has first go at it.

In the end, after all the time in the box for a lot of ATSB investigators, a nasty atmosphere and the coroner publicly ridiculing me for no good reason, the report stood and the Coroner made exactly the same findings - go figure. The Coroner had his opinions about the investigation - so be it - I have mine and I have a lot more aviation investigation experience.

Now don't get me wrong. If conducted in a non-adverserial, investigative manner, the results of Coroners Courts can be beneficial. But when lawyers are involved, anything can happen!

[Telefomen Trousers]

That's all good - but shouldn't the ATSB have arranged tox on the victims initially to confirm their theory re depressurisation? Why wait so long? It gives the impression that they had made their mind up already?

Di


"D" The ATSB does not control nor is it responsible for the PM and Tox process - that is under the control of the Coroners. The ATSB can only request that certain tests be done - and trust that the requested testing is timely.

Hope this clarifies your misconception.

[Lookleft]

Di and JE This is why the engines were not taken away for further analysis from the accident site. The investigators had already found evidence on site that both engines were developing power at the time of impact.

Left powerplant
The left engine and propeller remained connected as a unit throughout the impact sequence. The proximity of the engine and propeller to the left wing and fuselage at the end of the wreckage trail was consistent with the unit remaining with those parts of the airframe for most of the break-up sequence. The uniform, backward bending of the propeller blades and the chordwise blade surface scoring was typical of the damage sustained by propellers that encounter terrain or other high-density media at an acute angle while rotating under power.
<B> Right powerplant
</B>In contrast with the left assembly, it was evident that the right engine and propeller separated from the aircraft early in the impact sequence, as a result of the severe forces that compromised the right wing and engine mounting structures. Unconstrained in its subsequent motion, the trajectory, orientation and motion of the powerplant would have been governed by the reactive forces of subsequent impacts with objects and terrain in its path. As a result, therefore, an assessment of blade bending could not be reliably used to provide an indication of powerplant functionality. Indirect evidence that the engine was operational was provided by the propeller mechanism, with the extension of the pitch change rod from the front of the hub being an indication that the propeller blades were in the operational pitch range and had not been feathered. Chordwise scoring of the blade surfaces was evidence of propeller rotation during the impact sequence.

Conclusion
Considering the impact sequence and the nature of the airframe break-up as the aircraft descended into the terrain, the damage sustained by the aircraft powerplants was consistent with both engines operating and both propellers rotating with blades in the operating pitch range. There was no evidence to indicate that one or both engines had malfunctioned or sustained a power loss prior to first contact with trees/terrain at the accident site.

If you look at the supplementary report (which was issued partly because of JE's assertions about the right engine) it has a photo of the right engine's propeller separated from the hub. The props were still in the spinner but not attached to the engine. The spinner has the side profile of a dinner plate due to its impact with the trees.

If JE wanted to extract an engine from the site by helicopter at his own cost then that is his perogative (with permission from the owner one assumes), but the ATSB could not justify the cost of such an operation to prove what they already knew from on-site investigation.


I was there at the time of the crash (before the blizzard arrived at Hotham), and visited the site shortly after, with snow still deep on the ground. I also went on the 26th July 2005 when the snow started to melt, revealing stuff that was missed during the investigation. After the ski season, I lifted one engine from the site by helicopter, for further investigation.

JE The main issue is that the accident aircraft arrived at the crash site during the blizzard and was flown in a manner which gave the pilot zero margin for error.

[Diatryma]

Ogsplash,

Thanks for your post. Its good to get some first hand knowledge (on a "Rumour Network") - albeit some years down the track.

So I guess the question remains - can the ATSB arrange toxicology analysis if they require? Or do they have to go cap-in-hand to the local Coroner and wait for them to do so? I have assumed by the lambasting the ATSB received from the WA Coroner in this matter that the former was the case.


TT,

Thanks for your comment. However the misconception if there is one is not mine. It was the WA Coroner who reportedly lambasted the ATSB for not getting the tox reports until some years down the track. Also, forgive me - I'm not having a go at you - but I do not know if you are qualified to inform on the issue.


Lookleft,

I know the cost issue is often raised, but I would have thought:

(1) there would have been enough in the coffers to allocate to getting the critical parts of the wreckage off the mountain for proper analysis. We are not talking "sheep stations" after all.

(2) three people died in this accident - and it is not the sort of accident that happens every week (thankfully). Surely in deciding which accident to spend funds on this should have been one.

(3) the causes of this accident were not sufficiently clear (in my opinion for what its worth) for the ATSB to decide to leave the wreckage up there and not conduct a more detailed analysis.

All of the above leaves me wondering if the ATSB had an open mind -considering the pilot and his history.



Di :)

[Lookleft]

The Coroner will ultimately make up his/her mind based on the evidence presented. As part of the evidence presented the ATSB will probably be asked why they came to their conclusions about the engines and whether they were operating at the time of impact. The ATSB are not CASA and would not have had any prior knowledge of the pilot and the manner in which he operated prior to getting on-site. Their opinion of him would have been formed during the subsequent investigation and a large part of that opinion would have been formed when they got the radar plots of his two flight paths.

[Checklist Charlie]

Di

but I would have thought::ugh:

Item 1, pure guess, how do you know a "proper analyis" was not actually done onsite?

Item 2, read Aviation Decision Guidelines (http://www.atsb.gov.au/aviation/procedures.aspx) rather than guessing again that they should do something or other because you think it should be done.

Item3, in my opinion for what its worth you've already said you opinion is irrelevant.:ok:

Again you are airing a matter that you seem to have definite ideas about in the wrong place, go and talk to the ATSB and give them the benefit of your 'wisdom'

Charles:=

[Diatryma]

Chuck :yuk:,

Thanks for the constructive criticism LOL.

You really need to get a grip and lighten up mate.

Di :ok:

[Ogsplash]

'D', I no longer work for the ATSB so am unaware of the protocols in place these days. I think the thing to remember though is that the ATSB is staffed by some very dedicated people.

In the case of the 'Ghost Flight' (hate that title), any positive contribution that could have been made by the Coroner was lost in the 'noise' of the other comments and so, it seems, nothing much was achieved except to drive a wedge between the players.

Aviation accident investigation has a lot of pressure. Everyone has an opinion or an agenda they honestly (and sometimes not so honestly) believe in. Some are trying to prove a point, some want to make sure they're 'not in the gun' and yet others are looking for a monetary benefit. The media want instant answers which can never be made. It's amazing the focus that falls onto an aviation accident compared to all the other accidents that happen. An ATSB investigation tries to look at the facts and draw conclusions as to what happened...I was a strong believer in not providing scenarios because for every scenario I could think of, someone would think of three others! So, unless you had evidence supporting a particular hypothesis, I preferred to say nothing and say 'I don't know'.

[VH-MLE]

I seem to recall evidence given in the coronial inquest that the PIC did his "own ground school" (I assume this means home study) for his Kingair endorsement, which I personally found somewhat unusual given generally accepted industry standards (of a 3-5 day ground school) for an aircraft of this level of complexity because I think this was also the first turbine endorsement for the PIC.

I also seem to recall evidence that the PIC's endorsement was done in one day somewhat unusual too given the complexity of the aircraft involved.

I couldn't help but think to myself that the poor old pilot may have been behind the eight ball to some extent from day one irrespective of what may have occurred on that fateful night, however the ATSB didn't seem to flag training as a potential issue in this matter (openly at least) or if they did, it never rated a mention in the investigation report or coronial inquest.

VH-MLE

[Diatryma]

Death crash pilot chose most dangerous route, inquest hears - Local News - Geelong, VIC, Australia (http://www.geelongadvertiser.com.au/article/2009/07/29/88755_news.html)

A Geelong pilot flew across the most dangerous route to land at Mt Hotham airport, an inquest was told today.

The Victorian Coroner's Court was told Ceres pilot Russell Lee made no mention of an engine failure moments before a crash which took his life and that of his two passengers.

Instead he asked for the runway lights to be turned on.

Ewen Jarvis, a chief pilot as Essendon Airport, said it was unlikely there was an engine failure because that would have been the pilot's first priority.

He also said the path Mr Lee chose to take his passengers was inappopriate.

``It takes you over the highest terrain into the airport and takes you into a dead-end valley where you can't extricate yourself should you need to do so,'' Mr Jarvis said.

The hearing continues.

:sad: