Report of plane missing near Renmark SA

[Cloudee]

Adelaide media are reporting a beacon activation and missing plane in the Renmark area of South Australia. Channel seven news mentioned a 10 seat aircraft. There appear to be two rescue choppers heading to the area from Adelaide and Victoria on FR24. Lets hope for the best.


No Cookies | The Advertiser (http://www.adelaidenow.com.au/news/south-australia/plane-missing-in-riverland-after-activating-emergency-beacon-near-renmark-on-tuesday-afternoon/news-story/3497257d134465746943ca4632938103)

[Squawk7700]

Jeez that's not good, especially when they are talking ground based searches. Here's hoping for some good news.

Edit: the article has just changed with some bad news :-(

[dogcharlietree]

NEWSSOUTH AUSTRALIA

Three dead after their plane crashed near Renmark Aerodrome in the Riverland
May 30, 2017 8:00pm
The Advertiser
THREE people have been killed when their light aircraft crashed near the Renmark Aerodrome in the Riverland.

A SA Police search party found the plane wreckage about a few kilometres from the Renmark Aerodrome at 7.10pm on Tuesday.

All three people on board the plane were killed in the crash.

Two helicopters and a Royal Flying Doctor Service plane were scouring the Riverland area since the plane activated its emergency beacon near Renmark at 4.30pm.

[Richard C]

I live in the Renmark area (actually pretty well under the approach to RWY25) and conditions here today have been clear and cool with a southerly breeze. The terrain around the airport is pretty flat and varies from vineyards and orchards to areas of open mallee forest. Seeing an aircraft should be fairly straightforward if you are within a km or so.
If a beacon was heard and didn't give an accurate enough position to find the aircraft almost immediately and the aircraft has definitely not arrived at its destination, then it must have been a very short activation, which is ominous (implies fire).

[Richard C]

NEWSSOUTH AUSTRALIA

Three dead after their plane crashed near Renmark Aerodrome in the Riverland
May 30, 2017 8:00pm
The Advertiser
THREE people have been killed when their light aircraft crashed near the Renmark Aerodrome in the Riverland.

A SA Police search party found the plane wreckage about a few kilometres from the Renmark Aerodrome at 7.10pm on Tuesday.

All three people on board the plane were killed in the crash.

Two helicopters and a Royal Flying Doctor Service plane were scouring the Riverland area since the plane activated its emergency beacon near Renmark at 4.30pm.



Tragic news.

[Horatio Leafblower]

There is a website tht shows a Conquest going in there and scheduled to come out at about the same time. :sad:

[Pilotette]

Terrible news! Condolences to the family and friends.
Don't want to speculate but have heard it was a Conquest from a highly regarded operator in Adelaide?
Very sad.

[Cloudee]

There is a website tht shows a Conquest going in there and scheduled to come out at about the same time. :sad:
Yes and it was scheduled to go to YPAD and doesn't show as having arrived.

[mikewil]

The news is reporting it is a Rossair 'training flight'. As they don't do flight training, I can only assume it was a training flight for a new crew member.

[FRQ Charlie Bravo]

From Adelaidenow.com.au

A Rossair spokesperson confirmed its aircraft had been involved in the fatal crash.

“Tonight the loss of company personnel was profound for the families concerned and all company employees,"

So presumably all three were employees.

I've no idea who was onboard but I've known a few folks to have worked there. A very small but solid operator from all reports.

Terrible stuff.

[UnderneathTheRadar]

:sad: Explains why all the traffic in and around Renmark about 2000 local this evening - although 1 was medivac to Adelaide so maybe some survivors?

[D'pirate]

So sad RIP

[Sceva]

:sad: Explains why all the traffic in and around Renmark about 2000 local this evening - although 1 was medivac to Adelaide so maybe some survivors?

Sadly they unrelated medical flights...

Although one departing RFDS aircraft was involved in the search for a short time

[Desert Flower]

From Adelaidenow.com.au



So presumably all three were employees.

I've no idea who was onboard but I've known a few folks to have worked there. A very small but solid operator from all reports.

Terrible stuff.

No, not all employees. It was a check & training flight - outside people were involved. I know the identities of all 3, but personally only knew two of them. :(

DF.

[Desert Flower]

:sad: Explains why all the traffic in and around Renmark about 2000 local this evening - although 1 was medivac to Adelaide so maybe some survivors?

No, unfortunately not. :-(

DF.

[FRQ Charlie Bravo]

Desert Flower,

Understood. I think I've got it now.



Nice to read your name again after so many years, terrible that is under these circumstances. Take care, mate.

[aussie1234]

Sky news saying one of the people on board was from CASA.

[Left 270]

Same with 9 news, other crew named as well. Condolences.

[dogcharlietree]

Rossair grounds all flights, confirms chief pilot among three dead in Riverland crash - ABC News (Australian Broadcasting Corporation) (http://www.abc.net.au/news/2017-05-31/rossair-chief-pilot-among-dead-in-riverland-plane-crash/8574710)

[BPA]

Can anyone confirm if the Paul Daw (named in the article) is the sane Paul Daw who worked at CASA about 11 years and also flew the F70 in Europe?

[Capn Bloggs]

Shocking. A professional and true gentleman. Farewell Steve.

[Fantome]

"It doesn't destroy evidence (a fire) and that type of thing so we will be again taking our time to forensically go through everything in relation to the aircraft."

We may be sure on that - they will take their time.

[dogcharlietree]

7 News Adelaide‏Verified account @7NewsAdelaide 55m55 minutes ago
More
Renmark Plane Crash: RossAir crash victims confirmed as chief pilot Martin Scott, inductee pilot Paul Daw, CASA rep Stephen Guerin. #7News

[Jungmeister]

Can anyone confirm if the Paul Daw (named in the article) is the sane Paul Daw who worked at CASA about 11 years and also flew the F70 in Europe?

Very sad news indeed. Paul was involved in many aspects of aviation in South Australia and overseas, including those listed above. I guess an official confirmation will come from other sources.
Deepest sympathy to the family and friends

[BPA]

Very sad news indeed. Paul was involved in many aspects of aviation in South Australia and overseas, including those listed above.
Deepest sympathy to the family and friends

Thanks, he really loved aviation. I remember him telling me the about the incident in the Southern Cross replica when they lost one of the wheels.

Condolences to their family and friends.

[Fris B. Fairing]

BPA
The sad news has been confirmed this morning by Paul's brother Nigel. Paul was a total aviation person and a fellow historian. RIP Paul

[Engineer_aus]

Does anyone know if the Conquest had a FDR/CVR fitted to it?

All 3 men were highly experienced aviators and I know personally. RIP to all of them and blue skies gents.

[bradleygolding]

Very sad news. RIP.

Video of the crash site on Chanel 7 and 9 News. Looks very compact.

Steve

[kellykelpie]

So sad - Steve was a friend and a wonderful operator and wonderful person

[Obie]

Am I correct in assuming the accident occurred after take off from Renmark as against on approach to Renmark?

[FullOppositeRudder]

Yes - that's the assumption in all reports so far ..

[Obie]

Is the Conquest certified in the 2nd segment re EFATO?

[Sunfish]

God help CASA if one engine is found not to have been producing power.

[Squawk7700]

God help CASA if one engine is found not to have been producing power.

Context Sunfish, context... especially when media outlets are reading this.

Sounds like you're suggesting that if an engine has failed, CASA are somehow to blame....

[john_tullamarine]

Is the Conquest certified in the 2nd segment re EFATO?

Not familiar with the model but the TCDS suggests FAR 23.

[Sunfish]

The wreckage is unfortunately "compact". You know what that means.

Not suggesting failed engine Squawk, I believe the general opinion of pilots is that simulation of EFATO in a light twin is fraught with risk. Would I be wrong in believing the stories about CASA testing officers requiring or initiating the performance of unsafe acts that have been posted on Pprune?

Even on a single, it gets your blood racing when a testing officer pulls the throttle at low altitude to simulate engine failure, it must be much worse if it is done in a twin.

[Jabawocky]

Yeah.....I have been thinking the same thing all day, it sure sounds like another Air North Brasilia in DN type crash which took out the very guy who was implementing sim training only for the type.

Be sad if this is another similar event. :uhoh:

[Xeptu]

yeah sadly a known simulated failure training issue with the garrett fixed shaft engine at low speed, if you pull that power lever back too quickly and the negative torque sensing system doesnt get it quite right and the blades go negative you have just given yourself a Vmca event. It's not an issue with a real failure since the engine winds down and the blades go course. At high speed pulling flight idle quickly you do get a bit of assymetric yaw but at high speed its not an issue.

[le Pingouin]

It was prior to landing at Renmark (they failed to cancel SAR) but given the nature of the flight presumably they were airworking in the circuit.

[Cloudee]

The ATSB states the crash happened after take off from runway 25 at Renmark.

The ATSB is investigating a fatal aircraft accident involving a Cessna Conquest 441 aircraft, registered VH-XMJ, that occurred near Renmark Airport, South Australia on 30 May 2017.

The aircraft was reportedly conducting a training flight and collided with terrain shortly after departure from runway 25. All three occupants on board were fatally injured.

The ATSB has deployed a team of five investigators to the accident site with expertise that includes aircraft operation and maintenance.

While on site the team will be examining the site and wreckage, gathering recorded data including radio and radar, and interviewing witnesses.

The ATSB will issue a preliminary report outlining the facts of the accident within 30 days and present the findings of its investigation in the final report, due out within 12 months.

[Xeptu]

Yeah that's my understanding of it, had just taken off wreckage located 4 km's west of runway centreline, "if" a simulated engine failure it would still be in the second segment there.

[wishiwasupthere]

http://www.adelaidenow.com.au/news/south-australia/australian-aviation-expert-geoffrey-thomas-explores-probable-causes-of-the-renmark-plane-crash/news-story/6a29faf17e32dd7d3a7eb6fd3705c05b

Of course this f%¥king idiot pipes up when there's an accident with his utter tripe which somehow passes as 'journalism'.

[compressor stall]

I have a medical next week.... I wish I hadn't read that cr@p from that oxygen thieving baggage handler, it's sent my BP through the roof.

[Flying Bear]

My understanding is that the flight was possibly an assessment by CASA on the CP to issue him with check approval for the type within the Rossair training and checking system. This assessment was being conducted concurrently with the assessment of a new pilot to the company or similar.

If that is the case, then I feel that the challenge here is less about the risks associated with multi-engine training and more about the merits of a (technically) unqualified check pilot being assessed by a pilot (from CASA no less) who is not in a control seat, on a pilot who is undergoing a "live" check. "Check-itis" is heavy enough without the added layer of having two check pilots watching on, one who is under real professional pressure...

I've seen this before, and I reckon it can make for a very difficult cockpit environment, regardless of the experience of the personnel involved.

Finally, if the check pilot candidate sets an emergency scenario up incorrectly, who is going to fix it? The candidate undertaking the live check?? Certainly not the guy in the back, he has no flight controls...

[barbados sky]

Bear, I agree with you, I have seen it before as well but without such a tragic outcome. Our industry must learn to find better ways of doing things like this, albeit harder on older types with limited sim availability.

[Xeptu]

You're right Flying Bear, I have personally experienced this too and it's hard work, having said that I don't think this applies in this case. Paul was in fact quite experienced on the aircraft type and had in fact flown for Rossair before over a long period of time, he was simply going back after a long break. All of those on board were well known to each other, therefore the check environment would have been quite relaxed.

[OnTimeArrival]

Vale, Steve. Rest in peace.

[Band a Lot]

All of those on board were well known to each other, therefore the check environment would have been quite relaxed.



Not ideal!
In fact often no-one will say anything - when it goes pear shaped.

Someone asked before if there would be a CVR/FDR. Not required so almost certainly not.


Casa - video with audio works fine for what you are checking - that is procedures followed only.

[Horatio Leafblower]

Paul was in fact quite experienced on the aircraft type and had in fact flown for Rossair before over a long period of time, he was simply going back after a long break.

To me, Xeptu, this too is ripe with danger.
I didn't know anyone on that aircraft beyond occasional phone conversations. Nothing in the following points a finger or casts aspertions upon the 3 flight crew - but following from Flying Bear's comments, I have questions.

What had Paul flown in the intervening years? What were the power lever arrangements in those aircraft?
What had Martin flown in the last 10 years?
How much C441 time had Guerin flown in the last 3-5 years?
How much training had Martin received prior to this flight in his role as ME Instructor/Check pilot?

Was the power lever lifted over the gate and the Start locks engaged?
Did the pilot in the RHS pull the power lever back hard to flight idle?
Where were the hands? Who was holding what? what does the Rossair C&T manual say about who does what and with which and to whom?
Did someone fumble and **** up?
What other multi-faceted ****ups could have caused the holes to line up?

There are a huge number of questions raised by this one. 3 x very experienced pilots means that it could be a VERY interesting event.

A CASA FOI onboard gives us call to closely watch the ATSB investigation, especially in the light of the Norfolk Island investigation in which CASA was implicated and it appears ATSB acted to protect the Minister.

Vale.

[Xeptu]

All very valid questions Leafblower and something I have looked at over the years, how do we minimise risk while still achieving the objectives. One of the issues I have identified is that once a company has its delegations internally it becomes very insulated and over time think they are the best or at least pretty good at what they do, when in fact nothing could be further from the truth, who's going to tell them, their own line pilots, "not" I believe a good approach is to have these checkies inducted into other operators traing organisation to learn, share and develop methods and knowledge. Only then do we become worlds best practice.

[Horatio Leafblower]

Xeptu

Great point.

We have used Flying Bear and others. I look forward to Flying Bear's next visit to the (y)East, it is overdue :E

[The name is Porter]

I get the feeling that there will be some massive f@ckups identified in this investigation. I look forward to 2021 when the report comes out.

[The name is Porter]

I've got 3 students in the middle of MEIR, they look to their instructors for answers in these scenarios. You have your suspicions and I always say 'wait for the report' but when it comes out years later memories have faded and valuable recency of thought has been lost.

[Manubada]

RIP Steve G.


We shared many an hour on the (Kendell Airlines) M23 together.


One of the "old school" good fella's gone.


You will be remembered.

[Fantome]

To demonstrate competency in handling simulated EFATO, or any other emergency in the book, is not that complex or demanding. (It's not space-shuttle.) The dangerous , and in this case fatal, problem is not in any sense procedural . It lies in the embedded fraught issue of complicating the business of check and training with an underlay of unrealistic expectations. You have to consider the mindsets at work.
First impressions , what may have happened here, from reading the foregoing posts, is that there was a mix of competent but somehow distracted parties on board, not sharp enough at that time, on that day, in the prevailing circumstances, to foresee the hidden trap that was their undoing.

Whatever the final report comes up with, we may be sure that there will a significant element of conjecture. (Like the RAAF 707 off Sale, no one survived to add first-hand veracity to the conclusions.)

[Rashid Bacon]

CASA inspectors are just that - for the most part, they will not be current on type as in the context of someone who flies the aircraft regularly. Having done this role in a seat behind the crew, it also removes the inspector from the overall situation awareness.

One thing I always used to insist on during the briefing for these scenarios was a discussion on zero thrust, negative torque sensing and VMCA. I had speed and altitude margins that were conveyed to the crew members. Delaying initiation of throttle/thrust lever reduction by a few hundred feet and ensuring a speed margin provided an elevated safety margin (in my view anyway) and the trainee still got the intended training benefit.

As has been mentioned elsewhere, a real NTS event will result in rapid feathering and in many ways is less hazardous than a check pilot heads down at low level trying to set zero thrust.

This is not a criticism of what happened, but a reflection of the reality of checking and training where simulator support is not available.

My condolences to all those affected by this tragic accident.

[KRviator]

Yeah.....I have been thinking the same thing all day, it sure sounds like another Air North Brasilia in DN type crash which took out the very guy who was implementing sim training only for the type.

Be sad if this is another similar event. :uhoh:Just goes to show there are no new ways to kill yourself in aviation.

People just keep repeating the same old ones... :ugh:

[Slippery_Pete]

Let's just leave the speculative dribble to Geoffrey Thomas. I can't believe channel 7 persist with this guy.

There are no guarantees at this stage it was a VMCA incident. Let the ATSB do their thing and give the families and friends some space before we all go pontificating on wild guesses.

[Lead Balloon]

But the problem is that even if ATSB's competence and credibility had not been so compromised by events and reports over the last decade or so, it will still take years for a report to be produced.

Even if it's not out of its depth, it's stretched way too thin.

[PPRuNeUser0184]

Out of interest, how did Geoffrey Thomas become an "aviation expert"? What is his actual background in aviation?

[compressor stall]

KZ - Apparently he was once a baggage handler in Port Headland. I'm not aware of any other qualifications.

[Toruk Macto]

Condolences to family's and friends .
Is it %100 correct it was on take off or could it been a go around or missed approach off a practice instrument approach ?

[Paul O'Rourke]

ATC data was used for the last part of the recorded flight according to a web based tracker, at an altitude of 1250 meters (4100',) however, ATC coverage may extend a lot lower than that? Somebody else might be able to provide that information. ADSB is great for providing many paramaters such as velocity, altitude, rate of climb±, and track all timestamped in high definition creating a 3 dimensional picture of what is going on. This data would be of assistance in the investigation.

Would it be fair to suggest all check and training activities take place in a radar environment or airports that provide ADSB signal reception to ground level?


From Airservices Website (http://www.airservicesaustralia.com/wp-content/uploads/ADS-B-5k.jpg)
http://i692.photobucket.com/albums/vv283/PaulO-001/96ea945c-171a-4fc0-8f9f-405f7954532c.jpg

http://i692.photobucket.com/albums/vv283/PaulO-001/ADSB%20Coverage5000%20feet.jpg

[Xeptu]

Yes slippery pete I am speculating, it is however "educated" speculation, given the location, time of and disposition of the wreckage, it's difficult to imagine it's anything other than a stall/Vmca event for whatever reason.

[Richard C]

No Cookies | The Advertiser (http://www.adelaidenow.com.au/news/south-australia/australian-aviation-expert-geoffrey-thomas-explores-probable-causes-of-the-renmark-plane-crash/news-story/6a29faf17e32dd7d3a7eb6fd3705c05b)

Of course this f%¥king idiot pipes up when there's an accident with his utter tripe which somehow passes as 'journalism'.



That article is paywalled - and I've seen the sort of stuff he writes so I'm not paying to be annoyed.

[Richard C]

Yes slippery pete I am speculating, it is however "educated" speculation, given the location, time of and disposition of the wreckage, it's difficult to imagine it's anything other than a stall/Vmca event for whatever reason.



The photos of the wreckage certainly look like a low forward velocity impact.


Did we get an answer on the FDR/CVR question? Given the 1980 manufacture date, if fitted they'd have to have been later additions. It's occurred to me in the past that my car is better equipped for post-accident investigation than a lot of GA aircraft, just by having a $100 dashcam.


I didn't know Martin - he came on to the SA aviation scene after I retired but I first met Paul when he was in his 20s and worked with Steve when I was with KD in the 1990s. They were aviators in the best senses of the word and really nice guys too. They'll all be missed.


There's a Wikipedia entry on the crash that a contributor from the UK has slated for deletion on the basis that the accident is of little significance and "light twins crash all the time". Firstly I think it's a mistake to equate a C441 with (say) a C310, secondly this is the first fatal accident for an operator with 50 years of safe operation under its belt and thirdly I think this may be the first ever loss of a civilian turbine aircraft in South Australia.

[compressor stall]

[Firstly I think it's a mistake to equate a C441 with (say) a C310

Why? Are they certified to a different standard?

[Richard C]

Why? Are they certified to a different standard?



I was talking about the level of significance of the loss of one (I don't think the Wikipedia entry should be deleted).

[601]

I think this may be the first ever loss of a civilian turbine aircraft in South Australia.

VH-FMN at Mount Gambier.

[bradleygolding]

Out of interest, how did Geoffrey Thomas become an "aviation expert"? What is his actual background in aviation?

No idea, but the article I saw in the Advertiser today was utter drivel.

Having just read the ABC site, there is mention of a second wreckage site, but no details, so maybe it's not quite so straight forward.

Steve

[gaunty]

Stallie is quite correct, apart from different engines they are certificated to exactly the same FAR Part 23 performance requirements.
Significant issues, in the single engine case they are ONLY required to demonstrate the maintenance of level flight 5,000ft in ISA, and, EFATO a "positive" rate of climb. "positive" rate being min 50fpm.
There is no 1st, 2nd, 3rd or 4th segment climb gradient requirements as for Part 25 Transport Category types. There is OEI information in the POH and operators/pilots would be wise to include this calculation in their pre TO considerations.
We had an accident with fatals in a 400 series type over here where the "highly experienced" pilot decided to turn back, I don't think he got much over 200ft.

[gaunty]

Steve used to fly for me a good bloke and good pilot. RIP Steve.

[Capn Bloggs]

CASA Tribute to Steve:

https://www.casa.gov.au/media-release/tribute-casa-inspector-stephen-guerin

[BEACH KING]

Poor buggers.
I once had the pleasure of enjoying the company of one of these fellow aviators socially. A more humorous, informative, and engageable person would be hard to find.
It appears they perished enjoying their passion. Sad none the less.
Heartfelt condolences to family, acquaintances and friends.

[john_tullamarine]

Ref DF's query, aircraft are either State (military) or Australian (civil). RFDS will be on the Australian Register, ie civil aircraft.

[Slippery_Pete]

It may only be required to demonstrate FAR23 criteria, but the Conquest is quite the rocket ship.

I doubt the certification minimum reflects the actual capability in this instance.

[thorn bird]

The conquest may be a rocket ship, but cock it up and it becomes a missile.
Its a FAR23 aircraft treat it as such.

[gaunty]

The conquest may be a rocket ship, but cock it up and it becomes a missile.
Its a FAR23 aircraft treat it as such.
Quite so! And escape velocity is circa 25,000 kts, gravity and Newton therefore always wins.
My Conquest and Citation manuals are in a box somewhere in the garage, perhaps Leafblower could provide the OEI Climb rate for a MTOW and maybe lighter weights say half fuel for a C441 at Renmark.
From memory it might be from around 200fpm to higher when lighter but it won't be a startled gazelle and is only interesting unless you apply the actual climb gradient against the ERSA Runway Distance Supplement. This is a Requirement for Part 25 ops but not Part 23. Again my cranky memory suggests that the radio mast some miles to the West of Essendon R26 and the city skyscrapers off a take off to the South were real considerations. R21 at Perth has you busting through the Jandakot Airport circuit area at low level. Prove me incorrect if you wish. But remember the calls assume what could possibly go wrong.
I am surprised we are still having this discussion at this professional level. I gaurantee that for many of you a formal assessment of the EFATO runway and climb gradient performance against your regular destinations will bring a surprise. Regardless of whether it is a Part 23 piston or turboprop.
The reliability of these types is OK with the maintenance up to date but that doesn't protect you from a failure. A simulated EFATO, exercise if it must be performed, requires a very comprehensive plan and formal brief and the same detailed performance calculation as above as for normal ops and any eventualities.
QF's DeCrepignys experience in the very latest technology, what can possibly go wrong A380 even, is salutary and should be required reading.
Cessna also publish accelerate stop and go distances in the Manual, which properly interpreted can give you a means of applying a Claytons Part 25 profile alongside the calculated EFATO gradient.
It will of course be weight (not much) and or runway length (usually not enough) limited.
Unlike Part 25 equipment with the installed thrust and certification to meet day to day ops, Part 23 ops, which were never intended for fare paying pax in the first place, an EFATO is very serious high risk ****, more often than not mishandled, persistence simply takes you to the scene of the accident. The manufacturer says continued flight is the least attractive option and the least worst option directly in front of you is the best.
The regulator finally worked it out now requiring sims for the smaller turboprops and jets and the enlightened operators, like Leafblower, having protocols that recognise and mitigate the high risk. Yes sims cost if you have to travel but there is another even greater price.
40 year old complex airframe engine combinations are ripe with risk and failure potential. I used to sell these types new and operated them over many thousands of hours in charter when they were youngsters so I have a good handle on their potential weaknesses.
Let's see what the investigation produces but notwithstanding the experience and professional backgrounds involved I do hope we get a surprise.

[Xeptu]

so gaunty from a practical sense you would or would not fly the second segment

[Horatio Leafblower]

I offer the following with some reluctance. Without wishing to second-guess the crew, for I was not there, I have seen some crap on here (who'd a thought?) about what a Conquest can and cannot do.

My personal belief is that like the vast majority of accidents, this one too shall be largely due to the errors, misunderstandings, slips and other human failings of the very experienced and much loved people in the front. From the little I know of the background to this flight, I am of the opinion that it is the consequence of CASA bureaucracy and administrative intransigence rather than any innate failing of any of the 3 men, may they rest in peace.

Data at 1630 for 30/5/17 from Weatherzone.com.au
Performance data from AFM supplement for STC SA00487SE (GWI Phase I and II)

Renmark Elev 43'
QNH 1028.5 = Press ht -400' (say SL)
Temp 12.5

Assuming XMJ was at MTOW and had the VG Kit mod (cringes in anticipation of Gaunty's reaction to mention of VG kits)

Performance from the AFM gives a SE Climb rate of 648 fpm, which of course presupposes everything configured just so.

Stall Speed Flaps up/Gear Up 92 Kts, or 86 kt Flaps T/O
ASDR 3700' (1,127m)
Accelerate-Go 4340' (1322m)
Renmark is 1740m in length.

Takeoff Climb Gradient should be 3% at 100 KIAS, with gear DN and flaps TO (ie: 2nd Segment) . Wind was 8-12 kt SSW (maybe 4-6 kt headwind). RoC should be 300fpm.

OEI RoC 650 fpm @120kt with gear up, flap up, inop Feathered, 3-4 deg bank (ie: 4th segment). Usual Cessna subtractions provided of -300 fpm for Gear down, -200fpm for Flaps T/O, -800fpm FLaps LDG.

Nonetheless, that's a fair margin of performance before you start descending. By my reckoning that all exceeds the FAR25 requirements.

Some years ago when I did my C441 Endorsement with Flying Bear he asked what I had flown previously and I said that most of my recent multi was on a C404.
"Oh Good", he said, "The climb rate in a Conquest on ONE engine is very similar to that of a C404..." (My heart sank) "...on BOTH engines"

...and he was right.

While it is very nice to have all these simulators and things these days, I don't recall King Airs and Conquests dropping out of the sky 25 years ago when I was a young bloke. What has changed?

Gaunty, do you remember Conkys and King Airs falling out of the sky 25-30 years ago? They had simulators then. Why do you insist on simulators now?

I have strong views on this that I won't air here because I don't want people thinking I am judging the 3 good men lost this week.

...but the GA industry has to tighten things a bit and CASA has a role to play in funding and facilitating an investment in skills for the top layer of GA check & trainers.

[Xeptu]

perfect post leafblower

[Derfred]

Takeoff Climb Gradient should be 3% at 100 KIAS, with gear DN and flaps TO (ie: 2nd Segment)

Did you mean gear UP?

[gaunty]

Leafblower and Xeptu.
I had composed a response but when I hit the reply button it disappeared and told me I wasn't logged in, bugger its 2:30am so I'm off to bed.
For tomorrow.

[Fantome]

As with most fatalities, especially ones manifestly avoidable, in hindsight ,
the overwhelming emotion is an outraged , furious or endlessly questioning grief. Grief that any not intimately close to the deceased cannot begin to imagine.

CASA has a role to play in funding and facilitating an investment in skills.

Yes, (that's for the longer term) , and ATSB need to release their initial findings on the condition of the aircraft at the earliest possible moment. No prevarications , excuses or protracted delays this time. We can but hope.

[Horatio Leafblower]

Derfred


Quote:
Takeoff Climb Gradient should be 3% at 100 KIAS, with gear DN and flaps TO (ie: 2nd Segment)
Did you mean gear UP?

Takeoff Climb Gradient - One engine inoperative
1. Inoperative propeller - Feathered
2. Power lever - Takeoff Power - Condition Lever - TOCL
3. Landing Gear - Down
4. Wing Flaps - T.O.
5. Climb Speed - 100 KIAS
6. Windshield and Engine Anti-Ice - OFF

This is comparable to the OEI climb in the first segment.
I shouldn't have said "2nd segment" - as you correctly infer, that commences at gear up.
Where I stepped on my dick is trying to equate the performance of a Conquest to a Transport category aircraft, especially since it's nearly 20 years since I did my ATPLs :eek:

All the above and preceding guff presupposes that the failure was initiated correctly and safely by the check pilot and then handled correctly and safely by the candidate.
...and it is pretty adventurous to even assume (at this point sitting in my kitchen 1000km from the accident site) that the accident was caused by any particular action by anyone on the aircraft, let alone that it was caused by specific actions by specific people.

...so I'll leave it at that.

[Xeptu]

We’re all on the same page, our discussion is for those aircraft that can but are not certificated to do so. I suspect we here have been doing this for a long time anyway but we need to go one step further.

We need to take leafblowers claytons part 35 and decide as an industry with casa support what is in and what is not. For example we can leave the 1st segment out since it’s not practical, accept that if you reject a takeoff on a 1200 metre runway at close to V1 you are almost certainly going to run off the end and focus on what you do should that happen.

Keep the 2nd and 3rd segments, use 1.6 to 2.4 percent gradients, understand weight and temperature limits to achieve that, include either a curved departure or a single turn after cleanup at 400 feet onto an obstacle clear flight path to lsalt/msa, understand how to create such special procedures. Google earth in 3D is a beautiful thing for that purpose. Understand how that turn is conducted.
Understand how many track miles it takes to get to just 1500 feet over a 1.6% gradient. (12 to 15 Nm) and what you do from there, return or go somewhere else.

Hands up all those single pilot turbine drivers that read this with more than a passing glance.

[601]

do you remember Conkys and King Airs falling out of the sky 25-30 years ago?
No ...............

[Xeptu]

well to be fair 25 years ago there weren't that many of them, and unless you had 5,000 hrs space shuttle experience, you didnt even get to sit in it lol.

[Cloud Cutter]

Was the power lever lifted over the gate and the Start locks engaged?


That wouldn't be possible with the engine still running. Start locks can only engage with negative blade angle AND engine speed low enough for the springs to overcome the centrifugal force, i.e. during shutdown.

Simulating an engine failure on a Garrett is a critical exercise and I doubt you'd find any check pilot these days that would retard the PL to less than zero thrust (roughly 20% torque), or too quickly. Must be something else at play here.

[Xeptu]

Both correct statements cloud in the perfect world. The prop locks will be inspected in order to rule them out. Once everything that it wasn't has been ruled out, whatever is left however improbable must be the cause

[Desert Flower]

Someone wrote on Facebook that Rossair should ask the pilots who flew the plane previously that day about why the propellers weren't levelling out. Presumably she meant synchronising? I did ask her to clarify her statement but she didn't.

DF.

[Desert Flower]

From today's Adelaide Advertiser:

Authorities found the wreckage in the Cooltong Conservation Park about 7.10pm after the plane’s beacon was activated.

The ATSB is expected to remain on-site on Saturday and Sunday and may begin removing parts of the plane for further analysis.

Meanwhile, an online fundraiser has begun for Mr Scott.

An outpouring of support has seen the Go Fund Me initiative has raised more than $2600 for his family so far.

On Thursday, ATSB chief commissioner Greg Hood described the crash as one of the more unusual he had encountered given the vast experience of those on board.

He revealed the Cessna Conquest plane was only in the air for 60-90 seconds and reached an altitude of about 150m before it crashed.

DF.

[Lookleft]

That wouldn't be possible with the engine still running. Start locks can only engage with negative blade angle AND engine speed low enough for the springs to overcome the centrifugal force, i.e. during shutdown.

Simulating an engine failure on a Garrett is a critical exercise and I doubt you'd find any check pilot these days that would retard the PL to less than zero thrust (roughly 20% torque), or too quickly. Must be something else at play here.

On the ATSB website you will find a report of how an instructor managed to do what you say is not possible on a Brindabella
Airlines Metro over Lake George. Fortunately the "student" had the presence of mind to pull the fuel shutoff handle to shut it down.

[Judd]

Nonetheless, that's a fair margin of performance before you start descending. By my reckoning that all exceeds the FAR25 requirements
That "fair margin of performance" would be eroded in a flash if the throttle was left at the idle stop and the prop not feathered or, at the least reset promptly to zero thrust. i.e get rid of windmilling drag

[Mach E Avelli]

I am temporarily coming out of self-imposed exile to comment on this tragedy.

Too many here appear to have made up their minds that, because it happened on a training flight, pilot mishandling was the probable cause. Those of the unwashed public with sufficient interest would be gaining a similar impression.

The three pilots who died were not gung-ho amateurs playing at 'Top Gun'. They were mature, experienced and careful.

This training mission - in which the CASA Inspector was observing the Chief Pilot checking a very experienced inductee - would have been meticulously planned and briefed. Yes, there would have been some pressure on both operating pilots with CASA in attendance, but both would have experienced this before on several if not many occasions. Each of the three would have known the sequence of exercises, how and when emergencies would be simulated, and the speeds/pitch attitudes to be flown.

The Cessna Conquest 441 has benign handling characteristics and, as has been shown in an earlier post, good engine-out performance for its vintage and certification category.
BUT.....it is a 35 year old aeroplane not built to airliner standards of structural integrity or systems redundancy.

If pilot incapacitation can be ruled out (which we don't know yet) and the wreckage is too badly damaged to determine a mechanical cause, I do hope that the ATSB does not take the soft option of 'pilot error' ; rather returns an unresolved cause. With no CVR or FDR data, blaming the pilot(s) would be mere speculation.

[Xeptu]

actually mach Avelli you are the only one who has said that

[Squawk7700]

The talk of two crash sites that was mentioned in an earlier article is also relevant to the above (if true)...

[Horatio Leafblower]

This training mission - in which the CASA Inspector was observing the Chief Pilot checking a very experienced inductee - would have been meticulously planned and briefed. Yes, there would have been some pressure on both operating pilots with CASA in attendance, but both would have experienced this before on several if not many occasions. Each of the three would have known the sequence of exercises, how and when emergencies would be simulated, and the speeds/pitch attitudes to be flown.

The problem with what you have stated is that if you are correct, they have taken all reasonable precautions and it could happen to any of us.

...and none of us want to go to work tomorrow believing that. :sad:

[Desert Flower]

The talk of two crash sites that was mentioned in an earlier article is also relevant to the above (if true)...

Two crash sites?

DF.

[Xeptu]

Two Crash Sites

Yeah channel nine I think it was gave us a little pictorial suggesting a right circuit off RWY25 and crashing late downwind. it is in fact in the cooltong national park, near santos road, about a kilometre or two off the end of RWY25, the wreckage occupies a compact space of about 40 metres, all the essential components are present

[Desert Flower]

More from the Adelaide Advertiser website:

THE bent propeller from the doomed Rossair plane that crashed near Renmark, killing all three people on board, has been transported to Adelaide for further examination.

The propeller, with remnants of dirt still on it, was partly covered by a blue tarp and loaded onto a truck on Saturday afternoon as the Australian Transport Safety Bureau investigation into the devastating crash continued.

More parts of the nine-seat Cessna Conquest aircraft will be taken to facilities in the city for more detailed examination over the coming days while a preliminary report into the crash is expected to be released within a month.

Why only one?

DF.

[Cloud Cutter]

On the ATSB website you will find a report of how an instructor managed to do what you say is not possible on a Brindabella
Airlines Metro over Lake George. Fortunately the "student" had the presence of mind to pull the fuel shutoff handle to shut it down.

Thanks, I've had a quick look but searching for Fairchild aircraft with Lake George as the location yields no results - do you have an investigation number?

[Capt Fathom]

Try Fairchild, Canberra.

[Squawk7700]

The inference of two crash sites was not that it crashed at point A. versus point B... it was that the wreckage at first was believed to be in two separate locations with an inference of an in-flight breakup. Given what has been posted above, then that now sounds very unlikely.


The propeller, with remnants of dirt still on it, was partly covered by a blue tarp and loaded onto a truck

Given recent events at DFO, it sounds like they have covered up the prop to stop the "experts" from making early judgements.

[Lookleft]

I should have directed you to the common search engine but here is the summary. Report number 200404589

On 21 November 2004, the crew of a Fairchild Industries SA227-AC Metro III aircraft, registered VH-TAG, was conducting an endorsement training flight near Lake George, 33 km north-east of Canberra Airport. The flight included a planned in-flight engine shutdown and restart, conducted at an altitude below 4,500 ft (about 2,200 ft above ground level (AGL)). During the engine restart preparation, the instructor departed from the published procedure by moving the power lever for the left engine into the beta range and directing the pilot to select the unfeather test switch. These actions were appropriate to prepare an engine for start on the ground with a feathered propeller, but not during an airstart. As a result, the propeller on the left engine became fixed in the start-locks position. The crew lost control of the aircraft and it descended 1,000 ft, to about 450 ft AGL, before they regained control. The crew could not diagnose the source of the loss of control and proceeded to start the left engine while the propeller was fixed on the start-locks. As a result, the crew lost control of the aircraft for a second time and it descended 1,300 ft, to about 300 ft AGL, before they regained control. The SA226 / SA227 aircraft contain no lockout system to prevent pilots from intentionally moving the power lever into the beta range during flight. It was the first time the instructor had given a Metro endorsement and he was subject to time pressure to complete the endorsement. His ongoing difficulties in adapting to his employment tasks were not successfully dealt with by the operator. He had a limited understanding of the aircraft's engine and propeller systems, and had not practiced an airstart for 8 years as the CASA check and training approval did not include an assessment of all flight critical exercises.

The three pilots who died were not gung-ho amateurs playing at 'Top Gun'. They were mature, experienced and careful.

No doubt at all, but neither were the crew onboard the AirNZ A320 that crashed into the Mediterranean doing a pre-delivery test. Sometimes experience can work against you.

[spinex]

Given recent events at DFO, it sounds like they have covered up the prop to stop the "experts" from making early judgements.

I always thought there was an interesting parallel between those suffering a few loose screws and the apparent fixation with a few missing fasteners.

[Cloud Cutter]

I should have directed you to the common search engine but here is the summary. Report number 200404589.

Thanks for that - makes perfect sense in that context. There is no way for a propeller attached to a running Garrett to be placed on the start locks in flight - it's essentially water running uphill - goes against physics. This accident occurred shortly after takeoff, so I'd be very confident in excluding this as a possibility.

[KRviator]

Don't forget the crew flying the Beech 1900 around Willy that almost came to grief by setting Flight Idle rather than Zero Thrust and sinking back to around 100'AGL after takeoff...

The ATSB report (http://www.atsb.gov.au/media/24342/aair200000492_001.pdf).

[RubberDogPoop]

doubt at all, but neither were the crew onboard the AirNZ A320 that crashed into the Mediterranean doing a pre-delivery test. Sometimes experience can work against you.

..or the XL Airways A320 even...

[ChoppaGirl]

Let's just leave the speculative dribble to Geoffrey Thomas. I can't believe channel 7 persist with this guy.

There are no guarantees at this stage it was a VMCA incident. Let the ATSB do their thing and give the families and friends some space before we all go pontificating on wild guesses.

I was Martin's fiance and although I know we have to wait for the report, I do nothing but speculate as to what the hell happened. I find everyone's comments interesting.

[ChoppaGirl]

Poor buggers.
I once had the pleasure of enjoying the company of one of these fellow aviators socially. A more humorous, informative, and engageable person would be hard to find.
It appears they perished enjoying their passion. Sad none the less.
Heartfelt condolences to family, acquaintances and friends.
Sounds like my Martin 😀

[Xeptu]

My heartfelt condolences to you and your family, I feel your pain. Most of us crusty old buggers here have lost someone close over the years to our profession. It comes as a reminder of our unforgiving operating environment. If there's anything I can do for you.

[tfx]

Exeptu - "prop lock inspected in order to rule them out." Don't bet on it. They might be in pre-impact and out post-impact. Many things can change during breakup.

[StickWithTheTruth]

Does anyone know how ozrunways calculates altitude? If it uses baro pressure, the readings it recorded would not be correct in a pressurised aircraft or does it use gps?

Definitely GPS and it says "GPS ALT" in the altitude field.

Certainly not a silly question though,
as some of the Apple gear supposedly features barometric sensors.

[Cloudee]

Report out.
https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-057/What the ATSB foundThe ATSB determined that, following a simulated failure of one of the aircraft’s engines at about 400 ft above the ground during the take‑off from Renmark, the aircraft did not achieve the expected single engine climb performance or target airspeed. As there were no technical defects identified, it is likely that the reduced aircraft performance was due to the method of simulating the engine failure, pilot control inputs or a combination of both.

It was also identified that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained. That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats. Consequently, about 40 seconds after initiation of the simulated engine failure, the aircraft experienced an asymmetric loss of control.

The single engine failure after take‑off exercise was conducted at a significantly lower height above the ground than the 5,000 ft recommended in the Cessna 441 pilot’s operating handbook. This meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground.

While not necessarily contributory to the accident, the ATSB also identified that:


The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot. Therefore, despite having significant experience in Cessna 441 operations, he had reduced ability to actively monitor the flight and communicate any identified problem.
The inductee and chief pilot, while compliant with recency requirements, had limited recent experience in the Cessna 441 and that probably led to a degradation in the skills required to safely perform and monitor the simulated engine failure exercise.
The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure during the months leading up to the accident.
The Civil Aviation Safety Authority’s method of oversighting Rossair in the several years prior to the accident increased the risk that organisational issues would not be identified and addressed.

Finally, a lack of recorded data from this aircraft reduced the available evidence about pilot handling aspects and cockpit communications. This limited the extent to which potential factors contributing to the accident could be analysed.

[Xeptu]

I would like to see more of the evidence. The question as to whether or not the failure was initiated from V1 or at 400ft is important. If the latter is true then target speed would have been easily achieved and then some. There's little doubt that a Vmca event occurred. The question is why during a 40 second level segment did speed decay below Vmca. Flying directly into a setting sun would have been a significant factor, the rest is pure speculation.

1. What was the flap position
2. What was the blade angle of the propeller of the simulated failed engine.

[Lookleft]

Flying directly into a setting sun would have been a significant factor, the rest is pure speculation.

Isn't that statement in itself pure speculation? Why wouldn't everyone have their heads inside. The instructor monitoring the students actions and the student dealing with the simulated engine failure. The report states that there was limited information in which to base the sequence of events on. However the fact that it was a training flight and that the live engine, despite not having any defects, wasn't developing full power suggests that it was a training exercise gone wrong. Not an unusual event and why this type of exercise is best done in a simulator.

[Xeptu]

There's nothing speculative about where the sun was or it's effect. Yes both pilots would have been heads down, each pilot had different tasks and neither would be able to adequately monitor the others actions or performance in this condition. Neither pilot is likely to have been, lets say polished for this particular exercise. I'm not sure where you get the live engine wasn't developing full power, but it's fair to say if you knew you were going Vmca, pulling the live engine back would be the correct course of action on the part of the flying pilot
I wouldn't argue with a training exercise gone wrong or the benefits of a simulator. I'm not convinced that the exercise commenced at 400 feet, whats the point the takeoff is over, more likely to have been a V1 cut or once the gear is retracted. Nor am I convinced there wasn't an unexpected drag issue from the failed engine. 40 seconds in a level segment with speed decay is a very long time, even for the unpolished.

[Lookleft]

I'm not sure where you get the live engine wasn't developing full power, but it's fair to say if you knew you were going Vmca, pulling the live engine back would be the correct course of action on the part of the flying pilot

This bit:

It was also identified that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained. That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats. Consequently, about 40 seconds after initiation of the simulated engine failure, the aircraft experienced an asymmetric loss of control.

If you knew you were going Vmca then re-applying power on the "failed" engine would also be a good idea. just as it would have been a good idea with the Embraer in Darwin and even the 707 off East Sale. Maybe part of any EFATO briefing in a simulated exercise such as this one should include at what point the exercise will be discontinued but I think there is an element of press on-itis in order to tick a certain box. As for the exercise starting at 400' I don't think that is unusual at all. When I started conducting assymetric training in light twins my boss insisted that the exercise not be done below 400' as he had too many bad experiences with pilots he thought knew what they were doing.

[Xeptu]

Agreed and we'll never know what really happened. We only know what the power output was at impact. I concede my statement wasn't well said. In the heat of the millisecond you have to act you know power will come off instantaneously, but not necessarily the other way around.

Extended: Where I was going with that is that I have had a propeller going in the wrong direction, it was a split O ring on the propeller control rod, it was really difficult to find because the rod had to be in exactly the right spot to allow oil to flow in the wrong direction, causing the blade to go beta instead of course.

[VH-MLE]

One of the training issues to me is that retarding a power lever to flight idle instead of zero thrust seems to be an ongoing problem in these classes of aircraft & the cause of many loss of control accidents in training. From memory VMCA in the C441 was around 91 or 95 KIAS, with VYSE of 120KIAS, but I can distinctly recall our C&T pilot demonstrating that maintaining control was extremely difficult even at 120KIAS with a power lever fully retarded instead of at zero thrust.

This message does not seem to be getting through & in the absence of Australian based simulators for many of these aircraft, a stronger focus is required by CASA/ATSB etc...

I did not know the front seat crew members, however SG was a great guy & a very professional operator...

[Horatio Leafblower]

VH-MLE you are spot on.
ATSB blaming the operator's ops manual is bull****: For the purposes of the operation, CASA was the operator AND they had accepted those procedures in Rossair's manual.

SG should never have been in that seat and should never have put himself, or those pilots, in that situation. He was the pilot in command.

We have been doing Conquest endorsements in Australia since the first airframes were imported (ironically, by Rossair I think) in the 1970s. This is the first fatality. It speaks to the dwindling experience and judgement available in CASA, and the dwindling experience and judgement available in General Aviation at that time in particular, but across the last 20 years generally.

I have been doing Conquest endorsements for 6 years now and piston twin endorsements for 5 years before that. I am fortunate to have had Flying Bear as a resource and a mentor as I have learnt to teach Turboprop handling; but as a Chief Pilot and CFI most of my learning has been by trial and error. Some days I wonder if my survival to this point has been pure good luck.

CASA lacks the expertise, currency and testicular fortitude to provide industry development, preferring to pass the buck. It's time to ask Ben Cook, Tony Kern and other respected training leaders to lead a program to build industry capability.

[Hoosten]

And the report is spot on time, 3 years, awesome work!

[Centaurus]

most of my learning has been by trial and error. Some days I wonder if my survival to this point has been pure good luck.
Know the feeling. I was being checked out on the Cessna 425 Conquest. On the downwind leg of a left circuit, the chief pilot acting as instructor and at least 1000 hours as pilot in command on type, pulled back the throttle on the left engine against the idle stop. That is not zero thrust. Although initially flying at a safe speed I was unpleasantly surprised at the immediate speed decay and worse still my inability to counter the drag of the fully closed throttle setting.

Turning final towards the windmilling engine I doubted if I had the leg strength to maintain directional control. I remember telling the instructor there was no way I could maintain directional control if he asked for a single engine go around. He said nothing.

It was a struggle to stop it rolling into the dead engine. It was poor airmanship by the instructor and certainly endangered the flight. I didn't mind the simulated engine failure but his failure to set zero thrust as soon as I had identified the dead engine left no margin for mishandling. Frankly it rattled me and I had lots of hours on turbo-props.

It is a pity that ATSB do not adopt the FAA policy of publishing a most probable cause of an accident when there is insufficient evidence to produce an irrefutable cause. At the moment it becomes anyone's guess as we can see by Pprune comments and nothing is learned especially after three years. .

[Hoosten]

That scenario Centaurus is frightening. The fact that all of us following (instructing on these types) are relying on our mentors having to figure it out through trial and error in this country is also frightening.

[VH-MLE]

Unfortunately, that's GA in this country & no doubt most others that have a GA wing (pardon the pun...) in their country.

Also unfortunately, if you have a bad mentor - which may not be easy to identify whilst you're trying to learn/gain some experience/knowledge/judgement/wisdom, you are certainly set up for trouble with a capital "T".

Not saying there was a bad mentor in this tragic case as I don't have any knowledge of those involved in the front two seats or who their mentors might have been... Personally, I have always felt that the bulk of GA pilots receive far too little supervision/training for their roles...

Just my 2 lire worth...

[Lead Balloon]

Someone brought my attention to this in the ATSB Report. (I had to read this twice to make sure I wasn’t hallucinating): The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.So is that because the ATSB is gutless, weak, incompetent or just plain old corrupt?

Section 32 of the TSI Act says:32 ATSB may require persons to attend and answer questions etc.

(1) Where the ATSB considers it necessary to do so for the purposes of an investigation, the ATSB may:

(a) require a person to attend before the ATSB and answer questions put by any person relating to matters relevant to the investigation; or

(b) require a person to produce specified evidential material to the ATSB.

(2) Subsection (1) does not apply in relation to a person in his or her capacity as a coroner.

(3) The requirement under subsection (1) must be by a notice in writing. The notice must be signed by the Chief Commissioner and must specify the time and place at which the person is required to attend before the ATSB or produce the evidential material specified in the notice. That time must be reasonable having regard to the circumstances.

(4) When a person attends before the ATSB under paragraph (1)(a), the ATSB may require the questions to be answered on oath or affirmation. For that purpose, the ATSB may:

(a) require the person to take an oath or make an affirmation that the answers the person will give to the questions will be true; and

(b) administer an oath or affirmation to the person.

(5) A person to whom a requirement is given in accordance with this section must not:

(a) fail to attend before the ATSB in accordance with the requirement; or

(b) refuse to take an oath or make an affirmation when required by the ATSB to do so; or

(c) refuse or fail to answer a question lawfully put to the person; or

(d) fail to produce to the ATSB the specified evidential material in accordance with the requirement.

Penalty: 30 penalty units.

Note: Self‑incrimination is not an excuse for failing to answer a question. See section 47.

(6) Strict liability applies to the element of the offence against subsection (5) that the requirement is given in accordance with this section.

(7) A person who attends before the ATSB in accordance with a requirement under paragraph (1)(a) or (b) is entitled to be paid, in relation to that attendance, fees and allowances for expenses fixed by, or calculated in accordance with, the regulations.

What is that power for, if not to compel the provision of information and the answering of questions for the purposes of an investigation? You don’t “request”, you “require”. And you then prosecute those who fail to comply with the requirement to produce material and answer questions.

The ATSB was “unable” to make a determination about the circumstances under which the incorrect procedure was approved for use by the operator, because the ATSB failed to exercise powers that it has to obtain information about those circumstances.

There will some sophistry around words like “approval” and “acceptance” - a matter touched on in the report - but the bottom line is that the incorrect procedure got there ‘somehow’ and there should be records in CASA and knowledge in CASA about that ‘how’.

Astonishing.

[KRviator]

Know the feeling. I was being checked out on the Cessna 425 Conquest. On the downwind leg of a left circuit, the chief pilot acting as instructor and at least 1000 hours as pilot in command on type, pulled back the throttle on the left engine against the idle stop. That is not zero thrust. Although initially flying at a safe speed I was unpleasantly surprised at the immediate speed decay and worse still my inability to counter the drag of the fully closed throttle setting.

Turning final towards the windmilling engine I doubted if I had the leg strength to maintain directional control. I remember telling the instructor there was no way I could maintain directional control if he asked for a single engine go around. He said nothing.

It was a struggle to stop it rolling into the dead engine. It was poor airmanship by the instructor and certainly endangered the flight. I didn't mind the simulated engine failure but his failure to set zero thrust as soon as I had identified the dead engine left no margin for mishandling. Frankly it rattled me and I had lots of hours on turbo-props.

It is a pity that ATSB do not adopt the FAA policy of publishing a most probable cause of an accident when there is insufficient evidence to produce an irrefutable cause. At the moment it becomes anyone's guess as we can see by Pprune comments and nothing is learned especially after three years. .It's happened before, on many different types. People do not want to learn. Here's another example (https://www.atsb.gov.au/media/24342/aair200000492_001.pdf) this time, from a Beech 1900. Power back to flight idle, not zero thrust and they couldn't maintain control... Wash, rinse, repeat...

And what do you notice in the linked report?
Since 1992, it was the practice of the operator’s check pilots to simulate one-engine inoperative by retarding the power lever of the ‘failed’ engine to ‘FLIGHT IDLE’. That was contrary to the procedure prescribed in the Federal Aviation Authority-approved Beech 1900D Airplane Flight Manual, and also to that specified in the operator’s Civil Aviation Safety Authority-approved Training and Checking Manual. Reducing power to ‘FLIGHT IDLE’ also had the effect of simulating a simultaneous failure of the engine and its propeller auto-feather system. The simulation of simultaneous inflight failures was contrary to the provisions of the CASA-approved Training and Checking Manual. During each of the simulated one-engine inoperative sequences, control of the aircraft was not regained until the power on the ‘failed’ engine was advanced to the manufacturer’s prescribed one-engine inoperative thrust power settingSo for 8 years they had been intentionally violating their C&T manual and each time, lost control until they set Zero Thrust. :ugh:

[Horatio Leafblower]

It's happened before, on many different types. People do not want to learn.

I'd suggest people DO want to learn but often do not know what they do not know. Private Equity owners and champion Equestrians don't know what they are doing with flight training and don't want to invest the money when they just see another pilot that will "rip us off and leave as soon as the airlines call" or words to that effect.
The industry needs to develop a training program to build our capacity. It needs to bear the "authority" of CASA or ATSB; it needs to be credible and non-partisan.

Some in Government say to me it's up to Industry and "the Market" to sort this out but in our little corner of the world there are too many petty jealousies and historical rivalries for that to work.

CASA needs to provide leadership while there are still some in that organisation who know what that looks like.

[j3pipercub]

I think one of the reasons history seems to repeat itself constantly is culture. Bear with me. Individuals who become Checkers/Examiners in small time GA fall into 2 camps.

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA. They have seen their contemporaries go onto bigger and better things, they become resentful of the industry. As a result, this type of individual puts little effort into self improvement, as it isn’t their fault, it’s ‘the industry’. The flipside of this is these individuals are seen as a fantastic option to some operators as ‘they aren’t going anywhere’. So what you end up seeing is all the dregs floating to the top. These individuals often have little desire to teach, mentor or pass on knowledge to the next, younger generation of pilots. We have probably all met this type of individual and probably have fairly vivid memories of the meeting.

How do we cultivate a better culture and encourage a better sort of individual to stay in GA? I don’t know, just my ramblings from my limited experience. Better pay in GA maybe? No idea.

j3

Please note, this is in no way, shape, or form a comment on the Rossair accident or the individuals involved.

[Horatio Leafblower]

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA.

Sadly, largely, very true. The problem is that the ambitious people who want to make things happen (for themselves and others) actually DO make things happen, and move on.

I do wonder if the competent GA pilots that I have known would want to keep flying GA charter and instructing for $150k if they could chance their hand in the next biggest aircraft and continue to challenge their skills instead.

[Clare Prop]

I think one of the reasons history seems to repeat itself constantly is culture. Bear with me. Individuals who become Checkers/Examiners in small time GA fall into 2 camps.

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA. They have seen their contemporaries go onto bigger and better things, they become resentful of the industry. As a result, this type of individual puts little effort into self improvement, as it isn’t their fault, it’s ‘the industry’. The flipside of this is these individuals are seen as a fantastic option to some operators as ‘they aren’t going anywhere’. So what you end up seeing is all the dregs floating to the top. These individuals often have little desire to teach, mentor or pass on knowledge to the next, younger generation of pilots. We have probably all met this type of individual and probably have fairly vivid memories of the meeting.
.

Not all of us want the lifestyle that goes with airlines, that doesn't make us "dregs".

A number of real dregs end up at CASA; their appalling attitudes, immaturity and personal vendettas that made them unemployable in GA are then used to fuel their power trips. As someone who was "strongly encouraged" to apply for a job as an FOI and looked at the money and the people I would have been working with (been in the industry long enough to have watched their career paths, some who were still in primary school when I became a CFI) I declined, I prefer to potter around in my little four seaters and make a modest but satisfying living than share office space with (and being tarred with the same brush as) those same dregs.

[Super Cecil]

Sadly, largely, very true. The problem is that the ambitious people who want to make things happen (for themselves and others) actually DO make things happen, and move on.

I do wonder if the competent GA pilots that I have known would want to keep flying GA charter and instructing for $150k if they could chance their hand in the next biggest aircraft and continue to challenge their skills instead.
Instructing for 150K? Surely you jest?

[j3pipercub]

Clare,

Sent you a PM, I am not suggesting anyone that stays in GA is a dreg, that would be rather self depricating.

I agree with your comment regarding FOIs.

j3

[Hoosten]

Instructing for 150K? Surely you jest?

Prior to this mess there were quite a few G1's on 1 fiddy. Probably still are considering Flight Training is continuing. Although I reckon these salaries will be realigned quick smart.

[thorn bird]

But, But ,But, CAsA are the experts! aren't they?

How many CAsA FOI generated GA-isms float from Ops Manual to Ops manual around the industry?

GA-isms being a departure from widely accepted industry procedures or more specifically Flight Manual
or Pilot operating handbook manufacturers recommended procedures on the basis of CAsA expert opinions.

I've seen a few doozies at times.

[Hoosten]

The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

A morally bankrupt organisation.

So is that because the ATSB is gutless, weak, incompetent or just plain old corrupt?

All of that, and confirmed by their actions.

[VH-MLE]

Unfortunately, the ATSB are no longer at arm's length from CASA.

It wasn't that long ago that the ATSB had no qualms identifying any perceived failings when investigating an accident - including CASA failings. It used to be that they'd look at all the holes in the Swiss cheese, however as of at least the Pelair accident at Norfolk Island, they only really looked at the last piece of cheese i.e. the pilot in that accident and as a result, ATSB credibility has been shot to pieces. To my mind, this is due to the personalities & (cosy?) relationships that exist at high levels within CASA/ATSB/Government...

As stated above, the fact that CASA didn't supply requested/required information as part of an investigation & that this apparently was not pursued appropriately,only reinforces this viewpoint...

[Duck Pilot]

Part of the problem is that the CASA FCAT program inhibits FOI’s from remaining current enough to be safe, let alone being able to be in an operational seat to do any kind of assessment on a pilot or crew, particularly if any kind of simulated abnormals are required.

I know of an FOI who once tried to take off with the pitot cover on in a Twin Comanche whilst doing re-currency training, I thought something was wrong when the airspeed indicator started going backwards at about 40 knots!!!!

Part of the reason why I no longer work for CASA, I wasn’t sacked I was simply frustrated that I wasn’t given adequate opportunity to keep my fundamental cognitive skills proficient enough to the level that I expected of myself as a professional pilot. I know that a very large majority of current and past CASA FOIs will agree 100% with regards to this statement.

This accident should never of happened, CASA’s processes failed Steve and both of the two pilots who were tragically killed in this accident. The processes should never have allowed this training environment to occur. I bet nothing has changed and the same sh!t is still happening today.

CASA must let the current FE’s and Instructors do the potentially dangerous stuff, if it’s absolutely required. To many of these unnecessary training accidents have occurred over the years.

[Old Akro]

Part of the problem is that the CASA FCAT program inhibits FOI’s from remaining current enough to be safe

One wonders what the FOI was doing there? Ballast? The stuff about not being able to communicate and needing to tap the check pilot just doesnt pass the smell test.

And if they briefed beforehand on the tap signalling system, then surely the flight programme was discussed and the engine out procediure was part of the flight that was discussed with and approved by the FOI.

[Vref+5]

If the flying is too dangerous for a CASA FOI to be involved, then how is it safe for anyone else to be there? It’s just like saying that an unassessed building is too unsafe for an inspector to assess it, for the purposes of issuing a certificate of occupancy, but without the assessment it’s okay for people to live in it?? It doesn’t make any sense