Final report - accident at Croydon, Sept 2013

[outnabout]

Investigation: AO-2013-151 - Collision with terrain involving Cessna 206, VH-WAV, 156 km SSE of Croydon, Qld on 15 September 2013 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-151.aspx)


Amongst the findings:
"The distance available from where the pilot increased power for take-off was much shorter than the distance advised in the aircraft’s pilot operating handbook under the prevailing conditions.


There was no apparent reason for the pilot to attempt a take-off from that location when a more suitable location was nearby "


"the ATSB found that the pilot’s seat had broken from its mounts, probably as the result of heavy, unsecured cargo striking it during the accident sequence. This could have had a detrimental effect on the survivability of the accident. "


In the section relating to pilot's medical:


"Based on the available information, it was not possible to determine whether the pilot’s judgement of the available distance, or his decision-making capability, was affected by medical conditions and/or prescribed medications. However, the pilot’s medical condition and medications did have the potential to affect the safety of flight in general, and were only reported to the Civil Aviation Safety Authority (CASA) after the pilot’s medical certificate needed renewal. In addition, the evidence indicates that the pilot continued to fly without a current and valid medical certificate. "


In the section relating to aircraft maintenance:


"The most recent record of flight hours was dated 7 September 2013 and showed 7,006.3 airframe hours, or 101.7 hours since the last inspection. It was reported that the pilot carried out some minor maintenance, such as oil changes, between inspections.


Examination of the maintenance records showed that the aircraft accumulated more than the allowed 100 flight hours between periodic inspections on six occasions between 2009 and 2012, with 164.0 hours between inspections on one occasion."


Two people died as a result.

so long as some pilots continue to bend (or ignore) the rules, then we will always have CASA looking for ways to monitor, regulate & restrict GA.

[Avgas172]

So what part of the report do you attribute to the accident?

1.7 hours TIS overdue since the last 100 hourly
His current medical state
Or maybe due to self imposed work pressures he made a bad call.

Where is intervention by CASA going to stop this happening again? Sometimes in life we make bad decisions, god willing we survive those that we make.

[Jabawocky]

I know nothing of the prang or the operator, but I have formed this opinion purely on the report as written. And I must admit, I have some reservations about ATSB report accuracy these days.

The attitude displayed towards maintenance and general items of safety related to this, tend to conjure up an image of treating aviation like a landcruiser ute, abuse it till it drops, and they usually take way more than they should.

There is a historic pattern of not taking aviation with the seriousness it deserves and the he made a bad call. is the result of that.

Maybe I am reading it wrong. :sad:

[yr right]

There are no old bold pilots.

[Hempy]

He has a point. With no definite 'cause' the ATSB have tossed the ball into CASA's court in regarding pilot medical and aircraft maintenance.

"We don't know, but we'll throw our mates at CASA a bone".

It doesn't matter if those things had any bearing at all, this bloke may have just fcuked up. The fact that he flouted the regs though is now part of a public investigation. More fuel for those at CASA who believe that pilots are simply criminals that haven't been caught yet...

[yr right]

Things like this accident always make me wonder – how many accidents and damaged aircraft incidents are caused by 'operational expediency' – rush, push and tear arse???. No amount, or lack of 'regulation' will prevent these events from reoccurring. It's only going to result in a 'Local Council' like approach to regulation - to the unleashed dog rule i.e. all must suffer for the odd bad egg. Why not land at the ALA?- unload – drive 13 Kms, takes what – 20 minutes; so for the sake of a hour, all up, two lives and an aircraft are lost. All this to fix a bloody truck. Gut busting – and un required haste continue to claim lives.




Ive said it before the hardest word in aviation to learn is the word


NO

[Kharon]

[Croydon]. Also on board the aircraft were a passenger and some mechanical parts and tools, and the purpose of the flight was for the two occupants to conduct repairs to a truck at the work camp. The nearest purpose-built landing area was an unlicensed airstrip on the property about 13 km away.

Things like this accident always make me wonder – how many accidents and damaged aircraft incidents are caused by 'operational expediency' – rush, push and tear arse???. No amount, or lack of 'regulation' will prevent these events from reoccurring. It's only going to result in a 'Local Council' like approach to regulation - to the unleashed dog rule i.e. all must suffer for the odd bad egg. Why not land at the ALA?- unload – drive 13 Kms, takes what – 20 minutes; so for the sake of a hour, all up, two lives and an aircraft are lost. All this to fix a bloody truck. Gut busting – and un required haste continue to claim lives.

The pilot landed on a straight, unsealed public road about 650 m from the work camp at about 1200 and taxied to the camp using an unsealed private access road (Figure 1). The pilot parked on the access road and both occupants disembarked.

Here is another pilot, not declaring a medical condition. This is a real safety issue. Must we ask why, or is the answer self evident. It's time we started looking closely at and comparing to 'standards' required by other transport industries and developed a system which encourages reporting – with the focus on getting folk well and back into the air. If this guy was crook and the 'expert' medico's had declared him fit (with conditions), why should the CASA 'panel' feel it to be their duty to ground him – so long after the medical event.

Easy enough to say he'd stuffed it up, but the road to Stuffup City is well signposted.

[Old Akro]

how many accidents and damaged aircraft incidents are caused by 'operational expediency' – rush, push and tear arse???

There is absolutely no evidence to support this. Not a single scrap.

The accident happened at about 3:15pm and he was doing a 156km flight home. So there was not much pressure of daylight. There was a good chance he was just flying back for a beer.

The problem with many of the ATSB reports is that they use half information an innuendo to cast aspersions on the pilot when they don't have a better idea.

The pilot has clearly stuffed up. The aircraft was a bit over 1% past its due time for the 100 hourly and the pilot's medical was lapsed, however his local DAME and treating specialists thought he was fit to fly. But the crashed aircraft is testimony to an error of judgement.

But the ATSB report has a string of omissions & data presented in an incomplete manner which makes the pilot look worse.

And CASA's Avmed units performance gets away without comment. This guy went for a medical on May 23 and got the letter from CASA suspending his licence on September 11. Very near 4 months. And by the data included in the ATSB report CASA's judgment was in conflict with the treating specialists.

Look at the Casa DAME register and Croydon is over 500km from the nearest DAME, so dealing with CASA's inevitable questions would have been difficult. Finding a specialist with CASA credentials to counter CASA's opinion might have required herculean effort. You can't help but think that the whole medical issue would have had a different outcome in Sydney where you could readily see specialists to challenge CASA.

The things that disturb me about this report are:
1. It identifies that the pilots blood had opiates, but does not quantify the level. This sounds bad, but opiates include panadeine. If he'd popped a couple of panadeine for a headache earlier that day he would record opiates, but taking a panadeine for a headache conjurers a different image than painted by this report.
2. The report says he has a blood alcohol reading of 0.029. But the witnesses say he had not had a drink that day (the time was 3pm - so it was probably 15 hours or more since his last drink) and the fine print refers to a text which identifies that post mortem blood tests record inflated blood alcohol readings. Google post mortem blood alcohol and you'll find many similar references. I don't believe its clear that the pilot was alcohol affected.

Take away the alcohol & opiates reference and the ATSB case for clouded judgement is pretty tenuous.

3. I don't trust the ATSB measurement of take off distance. There is no reference to it being measured on the ground vs simply done in Canberra at someone's desk with Google Earth. How did they assess the beginning of the take-off run? The report refers to the point where witnesses heard the sound of the engine increasing power. But was allowance made for the delay in the sound reaching the witnesses? How good were the witnesses? Where were they standing?? Would the pilot really have left the nice straight section behind him? The ATSB report indicates they measured a straight line, but there is some ability for an aircraft to have a curved takeoff run. What difference does that make? Its feasible that these issues might make the take off distance acceptable.

4. The effect of wind is completely unclear. I have seem ATSB reports where they have gotten tailwinds & headwinds completely mixed up. This report does not give us any primary data. We don't know the direction of the road. We know some winds in other places, but there is no eye witness reports on the wind on the ground, nor discussion that the valley created by the trees either side of the road might modify the local wind.

If the aircraft took off with a headwind and the available take off distance was longer, then all of a sudden the ATSB's premise that the road was inappropriate is challenged. Is that why they don't present primary data?

5. The ATSB use take off data over a 50 ft obstacle, yet the report, says the trees were 25 -30 ft high. This means that the ATSB has not correctly used the aircraft performance charts.

6. There is inadequate discussion of recency. The report says that the pilot had flown 50 hours in this aircraft in the last 90 days - all in the aircraft and this his last flight was 7 days prior. He was current and knew the aircraft. But it would be germane to know what the flights were. If the pilot had been doing regular flights to this work camp, or was regularly landing on roads in the area, then casts the accident in a different light. The ATSB will (or should) know this history. Why do they not include a commentary on the pilot's experience landing on roads?

Seriously, if the ATSB can't do better than this, why don't we shut it down and bank the money?

[Clare Prop]

I donk know any of the circumstances around this, but do know that recently I had a very strong student "Freeze" and then put in some rapid nonsensical control movements resulting in a heavy landing and some nosewheel damage. He said afterwards that his wife, a doctor, would say "I told you so" and had told him not to fly when he has been taking Codral and he had been feeling anxious and disorientated.

During the insurance claim process I was told anecdotally that all recent claims have involved (mostly non prescription) medication.

I am now making it a much bigger deal than before with students that they must tell me if they are taking any medication especially if it ends in -eine. Including excess coffee or cigarettes.

[Jabawocky]

OA,

A very good analysis once again. :ok:

More questions than there are answers, once again.

:sad:

[Old Akro]

taking Codral and he had been feeling anxious and disorientated.

Codral is flu medicine. It is not a pain killer like panadeine. Codral includes an antihistamine. Its a completely different kettle of fish. From the Codral website:

Chlorpheniramine Maleate is a sedating antihistamine. It is used for the relief of a runny nose and watery eyes. As it is a sedating antihistamine, it also aids rest.

It carries this warning:

Be careful driving or operating machinery until you know how Codral Original Cold & Flu + Cough Day & Night affects you. This medicine may cause dizziness or sleepiness in some people. If this happens, do not drive or operate machinery.

[Clare Prop]

Old Akro,

Codral contains pseudoephedreine.

Side effects include dizziness and anxiety, he reported after landing that he had felt both.

The student's wife who is a doctor had told him not to take it. I wouldn't have done the lesson if he'd told me he had taken it. I can't take it before flying.

But hey what would I know, I'm just a dumb flying instructor who has survived 11,000 hours of students in various states of mental alertness.

My point was that non prescription medications are being more and more recognised as a cause of aircraft accidents.

[tecman]

I'm usually no great fan of ATSB reports but I don't see this report as the worst example of their recent output. The pilot had a serious medical condition reported fairly late in the piece, was taking various potent prescription drugs, was knowingly flying without a valid medical, was utilizing an aircraft (just) outside its legal maintenance regime and then, for whatever reason, the poor guy made the terrible decision to operate out of an unsuitable area. Frankly, I'd be more worried if the ATSB burned more of my tax dollars going much beyond where they ended up. I do agree that more could have been made of the surface met conditions on the day, had any sort of useful insight been available. But to argue the difference between 30' and 50' tree clearance in the use of the P-chart is really grasping at straws. A tragic and terrible outcome and, whatever you think of the report, more than enough lessons for us.

[Old Akro]

I'm usually no great fan of ATSB reports but I don't see this report as the worst example of their recent output. The pilot had a serious medical condition reported fairly late in the piece, was taking various potent prescription drugs, was knowingly flying without a valid medical, was utilizing an aircraft (just) outside its legal maintenance regime and then

Agree, but I don't think any of these things caused the accident.

The report beats the pilot up for not reporting his medical condition to CASA, but a) have you read CASR 67.265?? Every pilot in the country would just about be ringing CASA weekly if we obeyed it and b) no thinking pilot would ever report anything any earlier to CASA than was absolutely necessary. If you're not across this then 3 minutes searching pprune will give you a litany of stories of problems with CASA Avmed. Already Minister Truss has acknowledged that Avmed is a specific problem area and c) his treating doctors (DAME and treating specialist) thought he was fit to fly.

[tecman]

Definitely understand the frustrations of the AvMed environment, and appreciate the litany of complaints on this site. But these were no minor health matters and, when it comes down to it, you can't be buzzing around with no valid medical.

[Old Akro]

But these were no minor health matters

I don't know if they were or if they weren't.

But the ATSB report states that both his DAME and treating specialist said he was fit to fly.

you can't be buzzing around with no valid medical.

Agree 100%.

But I don't think it had anything to do with the accident and the ATS-B has not made the case that it has.

The pilot may have been a cowboy. I have no idea. But I object to the ATS-B using half truths and innuendo to paint a picture of blame on the pilot. The ATSB should make its point based on an argument supported with primary data.

[Old Akro]

Imagine if this crash had happened and AvMed had cleared him.

Lets try and think of some other reasons for the accident:

1. Good old fashioned poor judgement
2. A rut in the road, stick, roo, dog or something else on the road interrupting the takeoff run too late to abort
3. An engine fault restricting full power
4. A propeller fault restricting full fine
5. Wind shear at the tree top level
6. Cargo shifting and disturbing the CofG
7. Cargo moving and distracting the pilot of restricting his control application
8. The passenger grabbing the controls
9. Door opening in flight and distracting the pilot

If the pilot was properly licenced the ATSB might have had to do their job properly.

AvMed would be given heat for giving a pilot to clearance to fly on drugs that the ATSB report says may have contributed to the accident.

Or ATSB have written a report to support Avmed's decision. The Pelair report has proven that the ATSB is not as independent as we might hope.

[Avgas172]

Clare Prop, bottom line on your student really is that if he was affected by the Flu or Flu like symptoms ( I get this with a recurring sinus infection ) he shouldn't have put YOU at the risk he did regardless of which particular medication he was on. He is a student pilot, learning the skills required to commit aviation and needs 110% of his faculties just to strap in beside you.
Having said that love your work! :ok:

[gerry111]

Clare Prop wrote: "Codral contains pseudoephdreine."

Not any more, mate!

My packet of 'Codral Cold & Flu' lists Paracetamol 500mg; Codeine Phosphate 9.5mg; Phenylephrine Hydrochloride 5mg.

Then in italics: Phenylephrine replaces pseudoephedrine.

The change came about as Codral was being used to produce illegal drugs.

A real shame really as the new stuff is rather ineffective against flu symptoms, in my case. Now I just buy generic Paracetamol at 80c for 20 tablets of 500mg each. It works just as well for me. (Codral is well North of ten bucks for 24 tablets!)

I am certainly not a medical doctor. Please seek professional advice!

[Clare Prop]

Codral Original contains pseudoepehdreine and codeine. He did get medical advice, from his wife, who is a doctor, not to go flying when he had taken it. He ignored her advice and I'm sure she gave him merry hell for it when he got home. He didn't tell me he had taken it until we were filling in the ATSB report.

And as for ATSB reports, I have found any where I have known the details to be pretty inaccurate. eg I got one for flying over an inbound reporting point at the correct altitude and position but the Poliar aircraft put in a report....even though they were ORBITING :uhoh: close to it at the inbound altitude, and we were in Class G, I was visual with them etc. The report made me look like the bad guy!

[gerry111]

My apology, Clare Prop.

I'd missed the fact that 'Codral Original Cold and Flu' is still available from some pharmacies. I assume from behind the counter and hopefully only with a prescription. The 'Codral Cold and Flu, New Formula' on the shelves is the type that I described. And it is marked: 'Pharmacy Medicine'.