Partenavia fatal crash Wagga 1998. 17 defects present

[Judd]

It will be 22 years next month 20 July 1998, that Partenavia VH-IXH crashed into a hill during a DME Arrival into Wagga, killing the pilot and his passenger. The BASIS report stated: The pilot was operating the aircraft in IMC below the approved MDA and that low cloud was covering Gregadoo Hill (the site of the accident) at the time of the accident.. The pilot had been a flying instructor in his previous job and flying the Partenavia on charter work was his first job after being an instructor

The BASIS report: https://www.atsb.gov.au/publications/investigation_reports/1998/aair/aair199802757/

An inquest was later held at Wagga. Evidence was presented that the pilot had kept a hand-written list of defects relating to the aircraft. The BASIS report stated the aircraft’s maintenance release was valid at the time of the accident and no entries had been made in relation to outstanding un-serviceable items. It was reported that the pilot would inform the chief pilot of any maintenance action required and that would be coordinated with the maintenance organisation. The aircraft maintenance records contained no outstanding airworthiness issues.

The investigation team was provided with the hand-written note compiled by the pilot, which listed aircraft defects. The list was to be supplied to the aircraft operator and maintenance organisation for the next period of scheduled maintenance and identified items that the pilot considered could require attention. The BASIS team assessed the significance of the list and recovered some components from the accident site for more detailed examination. However, no evidence was available to suggest that the listed items had contributed to the circumstances of the occurrence.

The aircraft was equipped with a GPS satellite receiver and the pilot broadcast his intention to conduct the Albury-Wagga GPS Arrival. A ground based navigation aid provided azimuth guidance to the pilot.

At the inquest, the partner of the pilot gave evidence that the pilot had requested the list of defects on the hand-written note was to be given to investigators in event of an accident. The partner stated the pilot had frequently expressed his doubts concerning the state of airworthiness of the aircraft. In addition, he held concerns the security of his job would be compromised if he had recorded these defects in the maintenance release.

Following the accident, the partner of the pilot had given the hand-written list of defects to a BASIS inspector who expressed to the partner that as the aircraft was 25 years old, these sort of defects can be expected.

The following items were on the hand-written list and were un-rectified at the time of the accident.

1. Pilot’s left seat loose on rails and rocks fore and aft in flight

2. Brakes weak

3. Severe nose-wheel shimmy

4. ADF intermittently inoperative

5. Autopilot inoperative

6. Landing light inoperative

7.Cockpit panel lights inoperative.

8. Standby artificial horizon inoperative

9. Standby altimeter inoperative

10. No. 1 VHF Com aerial broken.

11. No. 2 Comm/Nav inoperative

12. Transponder inoperative (12 months)

13. Left engine oil pressure low light illuminated at all times

14. Left engine CHT low indication.

15. Nose-wheel oleo leaking oil

16. Rudder Trim very stiff to move

17. No shoulder harness installed

The inquest was told that many of these defects had been outstanding for several months despite passing the 100 hourly inspection.

Note: The writer was present at each day of the Inquest

"

[SITTINGBULL]

I may or may not know of a few IFR/VFR charter operators where this level of unserviceability is rife throughout their fleet...but the MR's are clean as a whistle.

I have heard these days that during CASA inspections or audits, companies are questioned on why a 40 year old clapped out 210/207/Chieftain or what have you, has a practically untouched MR. You only have to look at these things from the outside to know a defect list (most likely including but not limited do the 17 listed in this traigic P68 accident) should exist on the MR.

Pilots... and LAMEs.... are all too often between a rock and a hard place from the pressures of management to doing the professional & safe thing.

I guarantee that even today, ESPECIALLY in this current economic environment, pilots feel under the pump or in a position of low bargaining power because "If I endorse this MR, i'll be in the bad books and the I won't that twin upgrade" or "my employer will sack me on the next chance he gets, and I'll never find another job".

What really resonates with me about this accident is that I do know pilots of all skill levels keep diaries or send notes to the partners/loved ones for the "Just In Case" flights. All in the hope that CASA & the ATSB will use it in a way that pilots and future professionals alike will never spill blood over $h*t like this again.


Off topic scary thought: The notion that business owners are also operating as a HAAMC or the principal LAME fixing their own fleet. They might be one of the best engineers in the industry, thats great! But genuine Textron parts are by no means cheap. If your the one signing off an aircraft while also having to fork out cash for a new cylinder/cable/fuel valve or spar replacement, isn't their some conflic of intrest? ...Some laws need to be re-written.

[chimbu warrior]

It's amazing how some aircraft can fly 99 hours out of 100 without a single defect, but then accumulate 20 defects in that final hour before going in to maintenance. I guess some aircraft are just scared of hangars........

As an engineer pointed out to me, if there is nothing written on the maintenance release they can't justify investigating or rectifying any non-existent faults, and nor can they "discover" things that are only apparent when the aircraft is in flight. They also can't justify the extra man hours chasing defects that are "rumoured" to exist.

[sheppey]

Following the accident, the partner of the pilot had given the hand-written list of defects to a BASIS inspector who expressed to the partner that as the aircraft was 25 years old, these sort of defects can be expected.
The BASIS inspector was probably right. There would be hundreds of general aviation aircraft around Australia and currently flying that would be 25 years old or more. Based on the logic expressed by the BASIS inspector there would be hundreds of maintenance releases with numerous defects logged but with the aircraft still flying. .

More likely of course, those maintenance releases remain squeaky clean - just like the maintenance release of Partenavia VH-IXH before the aircraft hit Gregadoo Hill.

I recall an LAME being concerned about a damaged nose-wheel of a Partenavia brought into his hangar with every indication it had sustained the damage during a landing but not recorded in the maintenance release. When questioned if he thought CASA should be involved he agreed adding he would lose future work if it got around he had contacted CASA. Needless to say he failed to contact CASA despite the substantial damage to the nose wheel.

[neville_nobody]

The partner stated the pilot had frequently expressed his doubts concerning the state of airworthiness of the aircraft. In addition, he held concerns the security of his job would be compromised if he had recorded these defects in the maintenance release.

There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.

[Lead Balloon]

The chronic under-recording of defects on MRs is partly attributable to the persistent folklore that any and all defects entered on an MR result in the aircraft being ‘grounded’. But only partly. In the case of Partenavia VH-IXH the MR should have been endorsed: “Deathtrap”.

Then there’s the chronic problem of pilots who either don’t read or don’t understand an MR anyway.

Some pilots deserve the nickname “Deathwish”. Pity the poor bastards who are/were their passengers.

That’s a few decades and a few hundred millions in regulatory ‘reform’ for ya!

[machtuk]

There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.

Inhave to agree Nev. This is a well known issue within GA and pilots/engineers are their worst own enemies!
This will never change, not till the very last plane is either crashed or taken to the bone yard!

[compressor stall]

There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.
too right. I worked with Sam at the flying school where he was before this. I remember being extremely envious that he’d got the IFR twin charter gig. That school was a mess for various reasons (overseas cadets being promised a career based on the size of the parents’ wallets, not children’s skills). Any road out of that rut was paved with gold. This was the late 90s after all. “Whaddaya mean you’ve only got 2800 hours, this is a turbocharged twin!”

You were lucky to have any job. The balance between silence vs speaking up and never making it aviation was a fine line.

It may not have caused the crash (but may have been a factor through distraction or fatigue) but I can totally sympathise with his reluctant acceptance of those faults at the time.

[AmarokGTI]

I may or may not have worked somewhere where the CP said the only thing that can be written up without his approval is a taxi or landing light. (But not both). He also didn’t like being challenged as to why he thought a “gripe sheet” was better. One of those guys who bangs on about safety reports for everything. So I may or may not have put a safety report in about being told not to write stuff up. Weird bloody coincidence but next roster had no twin flying on it.

[Centaurus]

In another era I knew a DCA Examiner of Airmen (GA) based at Moorabbin. A former Army pilot, his advice was sought by many a young pilot starting out on his flying career. In those days Examiners were allotted 50 (?) hours a year personal practice, paid for by DCA. There was no shortage of flying schools at Moorabbin to choose from.

It didn't take long for the word to get around that he had no qualms about writing up a snag in the maintenance release where warranted. He would ring up various flying schools to make a booking only to be told by amazing coincidence all the aircraft were booked out. There was nothing he could do about it. He eventually took early retirement in disgust sickened by what he had seen.

Just think. if that sort of treatment could happen to a respected Examiner, what chance is there for the average GA pilot who needs to earn a crust?

Further to the subject of the Partenavia crash at Wagga. I did some of the pilot's instrument rating training prior to him moving to Wagga. He flew very well then. I warned him that out of the camaraderie of the flying school where he was a flying instructor, the world would be different as a charter pilot. That there would be subtle and not so subtle pressures to break the rules. That it would be up to his own strength of character to draw his own line in the sand. It has ever been thus in general aviation.

[Veruka Salt]

I was a bank run pilot in the late nineties, by coincidence based out of Wagga at the time of the accident. As Compressor Stall says, finding (& keeping) a twin job in those days was tough, so I empathise deeply with the commercial environment the poor guy found himself in.

[aroa]

Found and wrote up a defect in a jump plane. ... Corrosion pin hole in fuel line under the floor beneath the seat.
A/c had been flown in this condition for weeks by others and had red stains under the belly.. Found by chance as when replacing the floor hole cover . something moving reflected the light. Que.? Was the needle thin shoot of fuel hitting the floor side tin.... adding to a small puddle, Curiosity saved the cat.
It was the owner that blew up, (for the MR entry), fortunately not the aircraft.

[deja vu]

In another era I knew a DCA Examiner of Airmen (GA) based at Moorabbin. A former Army pilot, his advice was sought by many a young pilot starting out on his flying career. In those days Examiners were allotted 50 (?) hours a year personal practice, paid for by DCA. There was no shortage of flying schools at Moorabbin to choose from.

It didn't take long for the word to get around that he had no qualms about writing up a snag in the maintenance release where warranted. He would ring up various flying schools to make a booking only to be told by amazing coincidence all the aircraft were booked out. There was nothing he could do about it. He eventually took early retirement in disgust sickened by what he had seen.

Just think. if that sort of treatment could happen to a respected Examiner, what chance is there for the average GA pilot who needs to earn a crust?

Further to the subject of the Partenavia crash at Wagga. I did some of the pilot's instrument rating training prior to him moving to Wagga. He flew very well then. I warned him that out of the camaraderie of the flying school where he was a flying instructor, the world would be different as a charter pilot. That there would be subtle and not so subtle pressures to break the rules. That it would be up to his own strength of character to draw his own line in the sand. It has ever been thus in general aviation.
Yeah, a bit of drift here. I am not sure what happened there Centaurus. This may have been before my time but as I recall all examiners of airmen ( predominantly ex Military) were based in their citadel in the city. Flight Test Officers (vastly different pay scale to examiners) were based at YMMB and they had GA backgrounds, ex CFIs from Schutts, Civils RVAC, Pipair etc. mostly. In any case they didn't need to hire an aircraft to write up a defect. These guys spent their lives in and out of every "crate' on the airport. At least twice whilst being tested I was "instructed" to make an entry over fairly minor issues, in one case a windscreen change was required for some very insignificant crazing in one corner.( No MEL or ADD capability)

But yes, one charter outfit I worked for didn't permit pilots to touch the MR, a daily inspection was signed out by the CP or an engineer and daily hours tallied and entered at the end of each day. An exercise book was provided to make notes of defects and flight times. Pages could be torn out if they had the potential to be embarrassing or the book could be lost all together. That was 50 years ago. Not much has changed.

RIP all the souls lost to crappy maintenance.

[Ascend Charlie]

The group I worked for had their own choppers but hired Chieftain, Baron, or Aerocommander from an airport operator when needed.

On a SPIFR flight in a Chieftain, I reached cruise altitude, trimmed it, and engaged the AP. Very soon after, it developed a roll oscillation , increasing with time. Several retries later, I had to disengage it and go manually - not particularly legal. On return to base, I told my (non-pilot) supervisor that I thought the roll rate sensor was U/S. He said he would tell the owner and get it fixed - I was due to fly it again in 2 days.
Sure enough, 2 days later, with assurances it was fixed, same thing happened. On return I wrote it up in the MR, and immediately got a phone call from the irate owner who claimed he had spent $3000 fixing it the first time. Horsefeathers. But at least now, he had to fix it.
The owner, some years later, was in court over charges of giving kickbacks to my supervisor. Supervisor also in court.

[Bend alot]

The chronic under-recording of defects on MRs is partly attributable to the persistent folklore that any and all defects entered on an MR result in the aircraft being ‘grounded’.

It ceases to be Folk Law that every defect on a MR must be cleared, when CASA AWI's say they must be cleared.

[Lead Balloon]

It ceases to be Folk Law that every defect on a MR must be cleared, when CASA AWI's say they must be cleared.I look forward to meeting him. (A woman couldn’t be that thick.) I could do with some cheap entertainment.

I wonder how he explains the CASA rule about flights with unserviceable equipment:Where flight is conducted with unserviceable instruments or equipment ... the unserviceable instruments or equipment must be prominently placarded “UNSERVICEABLE” or removed from the aircraft.That rule refers to the rules about equipment for RPT, charter, aerial work and private aircraft.

https://www.legislation.gov.au/Details/F2017C01115

[Chronic Snoozer]

I wonder how he explains the CASA rule about flights with unserviceable equipment:That rule refers to the rules about equipment for RPT, charter, aerial work and private aircraft.

https://www.legislation.gov.au/Details/F2017C01115

Sheesh. Do you have a link to the version written for pilots?

[Lookleft]

Never in my RPT career have I had a placard labelled UNSERVICABLE in the flight deck. However I have had tiny stickers with illegible writing telling me that an MEL applies to a piece of equipment .

[Lead Balloon]

C’mon CS: That masterpiece is the product of about 30 years of simplification!

LL: I think you’ll find those tiny stickers were/are the attempt at complying with the placard requirement. It’s only been around for ... forever.

[Chronic Snoozer]

C’mon CS: That masterpiece is the product of about 30 years of simplification!

It’s lawyer porn. CASA’s version of the Tower of Babel. In my opinion, of course.

[Lookleft]

Sorry LB I was taking your statement about a placard being labeled UNSERVICABLE at face value as you being a lawyer and everything, you would be speaking in precise terms. We even have a big placard that states that the tech log is not in the flight deck. Have a guess how often that procedure is not followed. The pressure to operate when all the paperwork and and equipment is not up to scratch is ever present and the young bloke in his first twin job is less willing to resist it than the crusty old captain. Trust me the pressure to operate when the paperwork is not up to scratch is still present even at the jet end of the spectrum. Its just that age and wisdom give you the willingness to stand your ground and tell the appropriate people to fix it or we don't go anywhere. If you have never operated in GA as a young pilot flying twins knowing that the next step is a regional or mainline position then anything you say, can and will be used as dunny paper.

[Lead Balloon]

Yes - in the interests of accuracy I merely quoted the relevant rule, LL. That said, It may be that individual airlines have exemption and approval to use a different methodology as part of their system of maintenance.

I’m well aware of the delta between the theory and the practice.

All I can do is observe that, if something goes wrong because someone incorrectly assumed a system was serviceable because it should have been but was not placarded unserviceable, the theory will become important and people will come under a very different kind of pressure.

(In one of those many collections of humorous aviation stories there’s the one - perhaps fictional or perhaps I’m not remembering it correctly - about the pilot who complained that the aircraft’s autoland system was not working properly, resulting in a heavy landing, only to find that the system had already been written up as unserviceable. Or perhaps the system wasn’t fitted at all. Hilarious when it only ends in a heavy landing...)

[Lookleft]

All I can do is observe that, if something goes wrong because someone incorrectly assumed a system was serviceable because it should have been but was not placarded unserviceable, the theory will become important and people will come under a very different kind of pressure.

I can only agree with you in that regard. The Pelair Westwind and the KAL 747 cargo at are also testament to the dangers to the crew of an unservicable primary flight instrument. As you say the rules are black and white but the nebulous influence of pressure is what introduces the shades of gray.

[Sunfish]

It’s called the double bind problem.’’

https://en.wikipedia.org/wiki/Double_bind

[Lookleft]

No its called aviation.

[Lead Balloon]

Good news: The new, simple, outcomes-based rules will remove all the shades of grey.

[Centaurus]

Years ago flew a light twin single pilot Essendon to Albury. It had weather radar. Was somewhat mystified to notice all the mountains usually on the right (east) were displayed on the left (west) side of the radar screen.
On the way home back to Essendon, same weird display. Wrote it up in the maintenance release. The techs discovered the wiring to the radar was faulty and rectified the defect. That aircraft had been like that for months and not only did all the other pilots know about it (or maybe they never used the radar) but if they did, they didn't have the guts to snag it on paper.

Flew an Aero Commander for an Essendon operator Security Express. One of the pilots warned me the ADF only had five miles range. He was dead right.so I snagged it. The MR reply was Ground Tested Serviceable. Flew it again next day and same problem. Talked to the LAME who had signed it off as serviceable.

He said the ADF had been like that for months and all the pilots of Security Express were aware of it but had given up complaining verbally. Challenged the LAME why he had written "ground tested.. serviceable" when clearly he had not worked on it. He said he had contacted the aircraft owner who told him to sign it off as serviceable without looking into why the range was so poor. I don't know who owned that Aero Commander but he should have been hung out to dry by DCA.

[deja vu]

Centaurus, in the case of the Aero Commander you talk about it should be the LAME and the Operator/AOC holder who are hung out to dry.

[Sunfish]

As an occasional hirer from a club aircraft fleet, I got used to the phrase: “It always does that!” when discovering a snag.

’Well I don’t get used to it. In fact I’m not very good at handling “grey areas” at all.

Luckily for me they had a very good and understanding engineering group who were always helpful and I was always happy to wait while things got “adjusted”, however I’m not sure if the CP was impressed. I’m sure he labeled me a pain in the arse.