2 dead in Vic NW of Melb at Wallup

[Ultralights]

a lot of light rain in the Sydney basin wont get picked up by the radars at terry Hills, Wollongong, or Kurnell.

as the front passed last night, the radar return was showing heavy rain along the entire Sydney coast, just off the shoreline. yet there was no significant cloud in sight.

Atmospheric conditions can play some funny tricks with radar returns.

[Old Akro]

Atmospheric conditions can play some funny tricks with radar returns.

Agreed- but 3 triangulating radars and one with line of sight to the location?

[andrewr]

None of the Mildura, Mt Gambier or Melbourne radars show rain the in Warracknabeal / Nhil / Horsham Area. I take the point, but if nothing paints on any of the 3 surrounding radars, its hard to believe there was significant rain at the time. Especially since the Horsham METAR backs this up. Clearly it was a pretty bad day with earlier rain, but its rain at the time that counts.

My experience is that rain with nothing showing on the radar is quite common. It is usually drizzle from low cloud.

From the BOM web site information on radar:

Radar images on the Bureau's website show rainfall echoes from clouds located between 2500m and 3500m above the ground.
Generally, the optimal coverage area extends to approximately 200km away from the radar. Beyond this distance some rainfall echoes may be displayed on the radar image, however these echoes will be from clouds higher up in the atmosphere and will not directly correspond with conditions experienced on the ground.
All 3 radar sites are around 200km or more away from the area in question. They are borderline for coverage in that area at 10,000 feet, according to the BOM map.

The Horsham METAR would be for a very localized area, so couldn't be relied on for a more general picture of the weather in the area.

[Information Charlie]

R.I.P. Don. It was a long time ago now, but still have fond memories of the good old days at YBRS.

[outnabout]

After reading the report, I wondered: Is there higher country on a direct track between the Kenmore Gap and Nhill? (Not familiar with the area).


It looks to me like he was navigating from town lights to town lights, and missed a set of town lights. This may have contributed to him mistaking Wallup for Nhill, and he seemed to be wandering around looking for Nhill airstrip in the wrong area.






Add in last light, "must get home itis" from passenger, nervous passenger, unwell passenger, long day...sadly, a terrible ending.
I agree with previous comments that the report could be a lot more (factually) informative than it is, by including weather reports and other such pertinent information. Can anyone tell me why some information is included in the prelim report, but dropped from the final?

[Old Akro]

It looks to me like he was navigating from town lights to town lights, and missed a set of town lights.

Up until about Wallop there would unquestionably have been daylight. I don't believe he was navigating from town lights to town lights. (Also note that a number of the points mapped by the ATSB are not towns and do not have significant lights - including Wallup).

The ATSB conveniently don't show this detail, but he flew directly overhead Warracknabeal airstrip. You need to overlay the track on google earth to figure this out, mapping the aircraft route by reference to roads and paddock shapes.

From the take-off at Bendigo it looks pretty clearly like he tracked for Warracknabeal with some excursions off track for terrain or weather or both. Once he got to what the ATSB have labelled " Boolite" he changed course and flew a much straighter course which is the direct track to Nhill. My guess would be that he got Warracknabeal in sight and selected " Direct To" on the GPS and was tracking direct to Nhill. The point at which is changed direction direct to Nhill is about where the terrain becomes as flat as a pancake. The flight could have been completed at 200 ft AGL (or possibly lower) from this point.

The $64,000 question - which the ATSB do not really address - is why after nearly 10 minutes of straight, steady cruise (after the Boolite turn) did the changes of direction and wild speed excursions (+/- 20 kts) start? If he changed his mind about proceeding, you'd expect he'd fly 5 minutes in the opposite direction and land at the airport at Warracknabeal which he had just overflown. Note: Warracknabeal is a large 2 runway airport with a PAL equipped 1370m sealed runway. It would have been hard to miss.

If one was uncertain of position, the natural thing would be to fly to the lights of Dimboola (7 nm South), which I would expect would have been quite visible.

But given that he had (I believe) a yoke mounted iPad, I think he knew exactly where he was. I don't think the ATSB has correctly identified the cause of the accident.

[VH-XXX]

Why?

Disorientation due to the dark night conditions and it's why the ATSB are focusing on "dark" night conditions at present, aka ABC Marree Squirrel. Whether that be dark because of cloud cover, a lack of ground lighting reference or rain, it's the same result, a dark night. Like I said a while back in this thread, throw a blanket over the windscreen of the majority of NVFR rated pilots and see what happens.

[Old Akro]

XXX

I still disagree. The ABC accident was very, very different. I've flown in both areas at night and outback SA at night is a completely different experience. And the ABC chopper was just taking off and not established in cruise, whereas the Cherokee was in stable level flight and had been for some time. I don't think the 2 accidents can be linked.

This Cherokee was about 8 min after sunset, 12 min before last light with a clear horizon (below a BOM estimated 2,000 ft cloud base). He was flying west directly into the sun and would have seen every last ray.

The ATSB report says there were ground witnesses who could see the aircraft. My experience is that people on the ground cease to be able to see aircraft before the pilot ceases to see the ground. This supports my suspicion that it wasn't fully dark. And there would have been reasonable ground light and reflected light from clouds emanating from up to 9 towns within visible range.

[VH-XXX]

As much as we are not ATSB investigators and if we were sitting at the aero club bar, what would you say might have happened?

[Old Akro]

XXX

The first thing is that I think its worth noting that there has probably been more incisive debate on this thread than is evident in the ATSB report. The windmill I'm tilting at is that these reports are not transparent, do not present primary data, do not critically evaluate alternate hypothesis, and frequently present facts differently than the preliminary report.

The afternoon of the accident I flew into Tullamarine from Adelaide. I'd chosen a burner instead of my aircraft, so I was interested in how the weather actually turned out. I recall that it was better than I expected behind the front. While it may have been a putrid day, I'm not sure it was so bad at the time.

Despite the ATSB having METAR's , BOM observations, and eye witnesses, its evidence of the actual weather is scant. There is lots of rhetoric about how bad the weather had been, but very little on how it actually was at the time.

I started to become interested in this case after it came out that the pilot stopped at Bendigo and rang for weather. I reckon the decision to land is harder than the decision to stay once you've landed. So I was interested in what the pilot learned that would encourage him to keep going. I'm disappointed that the ATSB report gives no insight into this whatsover. But whatever happened was enough to coax nervous passengers back into the aircraft. I think we deserved a critical review of the veracity of the weather information.

If I were flying I'd get to Warracknabeal and think the hardest part is over and you could easily " straight line " the final leg to Nhill at 500 ft. You'd see Dimboola & Horsham on the left, then the runway lights at Nhill where you could do a straight in approach and get on the ground quickly.

If there was an autopilot on board (which the ATSB doesn't list) it would be a matter of engaging it and flying on for only about 10 - 15 min.

If you didn't like it a U-turn and a flight not much longer than you could hold your breath would get you back to Warracknabeal.

I know some guys at Yarrawonga (the pilots base) and have head some stories about the pilot. I was ready to blame the pilot, but now I just don't think its that easy. I'm not sure that the flight path fits with a pilot gradually losing spatial awareness either.

I think something else has happened. I suggest 3 hypotheses
1. the ATSB has made no attempt to explain the unfastened passenger seatbelt. They do acknowledge that the passengers were very anxious. To my mind, anxious passengers tighten seat belts, not remove them. I wonder if the passenger had a panic attack and distracted or disturbed the pilot.
2. I hear from Yarrawonga (and significantly omitted by the ATSB report) that the pilot had a yoke mount for his iPad installed the day before. I wonder if its batteries went flat and the pilot had become too dependent on it and became disoriented in his attempt to transition to another navigation reference. It would be nice to know from the ATSB if the iPad still had charge and what other navigation instruments it had (ie did it have an ADF which was tuned to Nhill??)
3. If this was the first time he used the iPad at night, was there something about its operation that was problematic - eg, was it too bright to see the AH clearly? Was the AH visible at all over the iPad??

I think there was a real opportunity to learn from this. Instead the ATSB has opted for the easy VFR pilot into instrument type conditions - blame it on the dead pilot pigeon hole.

[ForkTailedDrKiller]

The ATSB's conclusion and (1), (2) and (3) above, all result in the pilot losing control of the aeroplane - with the same outcome!

Dr :8

[outnabout]

Well said, Old Akro.

[Flying Binghi]

...the pilot had a yoke mount for his iPad installed the day before. I wonder if its batteries went flat and the pilot had become too dependent on it and became disoriented in his attempt to transition to another navigation reference...

If correct i think thats a major detail.

My first question about the ipad would be just how were it mounted? Did it obscure part of the panel?
The pilot, though night rated, planned for and set off on a day VFR flight - six pack not needed. Perhaps the ipad were mounted for an expected VFR flight in a convenient place to 'play' with the new nav device.

Possibility - Having an eight inch wide cockpit dominating bright screen presenting an illusory sort of artificial horizon jiggling just below the A/H would be very disorientating.

It is likely the ATSB have looked at far more then presented in the report. The dificulty i guess is writing a report that covers the main points the investigators believe to be the cause though is of sufficient brevity that pilots will actually read and learn from it. That said, it would be interesting to know more about the aircraft panel layout and more about that ipad?










.

[VH-XXX]

Possibility - Having an eight inch wide cockpit dominating bright screen presenting an illusory sort of artificial horizon jiggling just below the A/H would be very disorientating.

There is a dimming option at the top right of the screen (depending on the software he was using) that would bring it down to next to nothing brightness. I wouldn't go pointing at iPads just yet. If it is related to his iPad there's a very easy lesson for all of us in there to get familiar with any new equipment prior to flight, particularly a more "difficult" flight such as this one with additional hazards. Who knows, he may have been using an Ipad for ages and only coincidentally happened to have it yoke mounted more recently.

[Old Akro]

XXX

Agree - except that 2 years & 4 months ago iPads were not as common as now and I think OzRunways was still new and I don't think AvPlan existed. I think this was the old iPad 1 era???

But - why hasn't the ATSB addressed this in the report?

[Old Akro]

There are a few other details that might be germane too:

1. Did the aircraft have an autopilot?
2. If so was it coupled to a Nav source, or driven by the heading bug? Or was it a wing leveller? Was it operational & engaged?
3. Did it have a VOR? Was it tuned to Nhill?
4. Did it have an ADF? Was it tuned to Nhill, or Horsham or Warracknabeal? Were all these ground aids serviceable at the time?
5. Did the NVMC flight review (conducted a month earlier) cover navigation by these aids?
6. The ATSB said it had a panel mount GPS. Was this operational & programmed? Did it have an up-to-date database?
7. Nhill & Horsham have dial-in AWIS. Had either of these been accessed by the pilot?
8. Nhill, Horsham & Warracknabeal all have PAL. Had any of these been activated? The accident was less than 30nm from Nhill which is around the point I'd be activating PAL. Activation of Warracknabeal or Horsham may indicate a change of plan.
9. What altitude was he cruising at? (altitude excursions are graphed, but not altitude)
10. At last light, exactly which town lights are visible from this cruising altitude?
11. Did the ipad still have charge? If he hadn't charged it during the day, its battery life was probably struggling. Could the iPad running out of batteries be an issue?
12. Did the iPad have an external GPS unit? I've had some bizarre readings from iPads a bit North from this area when they lose the aid of Next G signal (without an external GPS engine) - especially with the early generations of OZRunways & iPad generation 1 - I sent OzRunways a number of screen shots of OZRunways showing the aircraft tracking 90 degrees from its actual course about 50nm North from the crash location.
13. Was the iPad mount a propriety one? Or a home made jerry-rig thing? Was it fitted and / or signed off by a LAME? Did it obstruct view of the instrument panel?

This might be the first accident where an iPad was relied upon for navigation (if not used for primary navigation). Nearly 2 1/2 years ago the EFB rules were significantly different. You'd think a review of EFB use might have been relevant.

A question I would have liked considered is: Is it possible this flight would have had a better outcome if he had used flight following? Basically, I only fly 8/8 blue VFR or IFR, so I've never used it. But I hear a lot of guys being denied it on the radio. But should we be encouraging the use of flight following in difficult VFR days like this? Would it have made a difference?

I've had experiences in Western Victoria where the actual weather was nothing like the forecast. I was hoping for an analysis of the forecast the pilot received vs actual. The guy landed at Bendigo because he didn't like the weather. What changed his mind? Frankly, I think a thorough report would have appendixed the actual report. And why was the Horsham METAR included in the preliminary report deleted from the final report?

The benefit of asking these questions is that it might provide flight preparation lessons rather than simply blaming the pilots night proficiency (despite it being greater than required by CASA regulations).

The only lessons from this report are to ring the elaborative briefing number rather than rely on the NAIPS briefing and to fly more and be more proficient. I don't think there enough analysis in this report which would cause a NVFR pilot to do anything differently. I don't think its achieved its objective.

Anyway, its time to move on. It was a very sad accident. The pilot clearly made some errors in judgment, but also his actions at Essendon and Bendigo also suggest he did some good things to try and get good information.

My main issue with this thread is that after 2 years and 4 months, I think the ATSB have done a very poor job of investigating it.