VFR into IMC ATSB investigation

[archangel7]

https://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-009/

It just amazes me that with todays technology pilots still get caught in these dangerous situations yet it is still common scenario. Are we becoming too reliant on the technology these days? A pilot may decide to ‘press on’ into deteriorating weather, either unable or unwilling to see the increasing danger of their actions, until the aircraft suddenly enters IMC.

[Squawk7700]

Would love to see the ATC transcript.

The way I read it, is that the instructor said screw this scud running crap, I’ve got a Goldfish to feed, I’m heading home VFR in IMC.

Presumably they were qualified personally to do so, or experienced enough to get away with it. If the pilot and aircraft were IFR capable, you’d have to assume they would have upgraded.

[jonkster]

I cannot comment on the actual incident here but I think at times there can come a point when it may be safer to go IMC than try and stay under cloud. Obviously avoid getting into the situation in the first place but the typical scenario we teach students where it is described as you "accidentally enter cloud" so "you need to do a 180 on instruments and exit it" is not particularly realistic or reflective of what happens in real life (IMO)

I think a lot of VFR into IMC happens much more gradually and insidiously and by the time you are in IMC a 180 turn is not always going to help.

The old ASD has an article (#133 1987 "Kilmore, apt - but sad") about a pilot who kept pressing on under weather into rising terrain (Kilmore Gap) hoping it would improve.
https://www.atsb.gov.au/media/5774829/asd_133_win_87.pdf

The final accident report on that accident not quite as the detailed as the ASD is https://www.atsb.gov.au/media/27716/aair198302279.pdf

In that case pilot had many options to turn earlier but when he was really in trouble perhaps the best option may have been to climb rather than a simple 180 turn back to where he had been visual.

[Capt Fathom]

The way I read it, is that the instructor said screw this scud running crap, I’ve got a Goldfish to feed, I’m heading home VFR in IMC.



Amazing insight!

[Squawk7700]

Amazing insight!

Imagine being an IFR qualified instructor in an IFR equipped aircraft being flown by a low time student and you want to get home to feed your goldfish and not spend the night at the Hamilton Golden Chain motel.

You may be right there Jonkster, we often focus on the negatives, but in this case they may have taken the safest option.

[Mach E Avelli]

The PIC took control, requested ATC assistance and landed safely “ The investigation is continuing “. What more is to investigate? Has the ATSB no other ‘crimes’ to solve?
Perhaps I could give them a list of the errors of judgement I made in my career, which (fortunately) I extricated myself from.
Now THAT would occupy their tiny minds....

[Squawk7700]

The PIC took control, requested ATC assistance and landed safely “ The investigation is continuing “. What more is to investigate?

The instructor took control, then climbed, then entered IMC. I guess the question is why?

[zanthrus]

Mach E Avelli, We all have a few of these stories we COULD share. ;) (Sorry, not sorry CASA but I'm not going to.:) ) I agree with you that in this case there is nothing to see here. Well done to the Instructor.

[Strainer]

Imagine being an IFR qualified instructor in an IFR equipped aircraft being flown by a low time student and you want to get home to feed your goldfish and not spend the night at the Hamilton Golden Chain motel.

You may be right there Jonkster, we often focus on the negatives, but in this case they may have taken the safest option.

The most important question here is ‘Well fu*k me! What’s wrong with the Hamilton Golden Chain motel?’

[Squawk7700]

The most important question here is ‘Well fu*k me! What’s wrong with the Hamilton Golden Chain motel?’

It must be bad if it’s worth punching into IMC and declaring an issue to ATC.

[The Bullwinkle]

The most important question here is ‘Well fu*k me! What’s wrong with the Hamilton Golden Chain motel?’
No, this is the most important question; How is the Goldfish?

[compressor stall]

There might be something to investigate here, and I am not talking about the PIC's command decision that saw a safe outcome.

Why did BOM get it so wrong? Are they under resourced, inexperienced etc?
Does the flying school set out on VFR flights in conditions that arenot suitable (might be a trend re the fatality a few years ago).
And maybe something else I have not thought of.

[Capt Fathom]

Problem with BoM these days is they rely solely on computer modelling to forecast weather.

Local forecasting experience has been forgotten or ignored!

[compressor stall]

Problem with BoM these days is they rely solely on computer modelling to forecast weather.

Local forecasting experience has been forgotten or ignored!

... which may be a factor in this incident, hence continued investigation.

[ShyTorque]

Is there any reason why a qualified pilot in that part of the world can't change from flying VFR to IFR after departure? :confused:

It's by no means unusual in this part of the world and certainly no reason for an official inquiry.

[UV]

I agree with SkyTorque, in the UK it happens all the time. Many times an aircraft operating from an airfield with no approach aids will divert into an Instrument equipped aerodrome.

We even have a thing called the Strasser Scheme which encourages it and many airfield/airports in the UK will waive landing fees for genuine weather diversions.

No questions, no inquiries, nowt!

Could it be that the Australian weather (unlike European weather) is either so settled/unsettled that this non event (to us) sparks an inquiry?

[megan]

Is there any reason why a qualified pilot in that part of the world can't change from flying VFR to IFR after departureUnless things have changed since I gave up never used to be.

[jonkster]

The incident reported is of a VFR flight that went into IMC, (not that they changed from VFR to IFR).

I would assume from that wording, the aircraft or the instructor were restricted to VFR ops (eg aircraft not having suitable equipment or pilot not having a current rating etc).

[IFEZ]

'I would assume from that wording, the aircraft or the instructor were restricted to VFR ops (eg aircraft not having suitable equipment or pilot not having a current rating etc)'

Yes I was wondering about that. I flew that particular aircraft a few times (although it was quite a few years ago now) and I seem to remember it as a pretty bog standard Warrior and not equipped for IFR. I guess it could have been upgraded in the years since. Hard to comment on the instructors decision making without knowing all the facts, but from what I've read so far he seems to have done well to extricate them from what could have been a nasty situation. Looking forward to the report coming out by 2024 :ugh:

[deja vu]

The most important question here is ‘Well fu*k me! What’s wrong with the Hamilton Golden Chain motel?’

Like most motels the bed cover is carrying 120 different DNAs. Think about it.

[Cloudee]

Report out. https://www.atsb.gov.au/media/5779981/ao-2021-009-final-report.pdf

“The ATSB found that although the flight crew had conducted a pre-flight briefing, they did not detect the forecast deteriorating weather in the Warrnambool area. In addition, they did not assess the aerodrome forecast for both Moorabbin and Warrnambool to ensure they were suitable destination airports. The aircraft departed Warrnambool in visual flight conditions however, as forecast, the weather subsequently deteriorated and the flight crew initiated a return to Warrnambool. During the return, the conditions reduced below that required for visual flight resulting in the VFR certified aircraft entering instrument meteorological conditions (IMC).
After entering IMC, the pilot requested assistance from the controller and maintained control of the aircraft.”

[deja vu]

Has anyone else noticed the use of the woke pronouns now in these reports.

Your public service at work, they have decided that they have no need to use correct English grammar any longer.

[Lookleft]

Let that be a lesson to any instructor who expects the student to brief them on the weather. The instructor should already know what the weather is doing especially someone who has a ME-CIR. With the information available at the touch of an ipad including hi res sat pics then there really is no excuse. Hopefully the instructor has learnt a valuable lesson about what PIC means.

[43Inches]

Hard to comment on the instructors decision making without knowing all the facts, but from what I've read so far he seems to have done well to extricate them from what could have been a nasty situation.

What's the old quote; "A superior pilot uses his superior judgment to avoid situations which require the use of his superior skill...."

The report highlights that a few errors of judgement led them into the situation, something we can all learn from. Luckily the instructor had the skill set to survive the event and we can join them in hindsight as to what additional precautions one could have taken.

I think one key thing that is not stressed is the build up of delays that led the flight running into the weather they were trying to avoid, it is mentioned but not in the summary. I've seen this a lot over the years even at airline level, a few minutes here and there not accounted for and next thing you are smack bang in a front you were hoping to beat, hopefully in the right equipment to deal with it.

As far as telling pilots not to push weather while VFR, not sure you can do much more, the history is there, statistics are well established, pilots still do it.

[On Track]

Exactly, deja vu. That report is riddled with grammatical howlers and therefore unacceptable.

[andrewr]

One thing that might have been looked at a bit more closely was the weather forecasting.

I am not a fan of the GAF, I find it much harder to interpret than the old area forecasts. I suspect pilots are departing with much less understanding of what weather can be expected than with the old forecasts.

Old forecasts: You knew what weather to expect, but sometimes it was unclear where it would be. GAF: You know where the weather will happen, but not what the weather will be. The report seems to illustrate this point, including the chart from the GAF but not the table with the actual weather.

Also, I have noticed the BOM have a regular habit of issuing a TAF for good weather, and then amending it when the weather turns bad (or just prior). This might be measured in the KPIs as an accurate forecast, but is not much help for planning a flight. That also appears to have happened in this case.

[Lead Balloon]

Hear! Hear! andrewr.

[43Inches]

Also, I have noticed the BOM have a regular habit of issuing a TAF for good weather, and then amending it when the weather turns bad (or just prior). This might be measured in the KPIs as an accurate forecast, but is not much help for planning a flight. That also appears to have happened in this case.

I regularly ring the BOM if a forecast looks suspect, like fog lingering or METAR disagreeing with the TAF. What I've found is that whatever flags the issues just does not get picked up at country ports, this is even more a problem when they are focused on bad weather at a major port. This is nothing particularly new though, there's a few ports I've flown to that have local conditions that catch the BOM out regularly and are predictable if you have local knowledge.

The weather forecast is an educated guess by professionals trying their best. Always study not only the minimum legal forecasts but surrounding area forecasts and actual condition for prevailing trends, the overall trend picture will be more valuable to planning than hoping on one TAF, it will also show up if the TAF possibly has errors. In this case the weather forecast was not at fault, it was accurate at the time of planning. Possibly there were comprehension issues, GAF issues or not. This was a training flight, the instructor MUST be able to read and understand a GAF, what on earth is being taught to the student if the Instructor has no idea.

The student didn't inform the instructor of the weather from 1400-1500 as they were meant to land and depart before its onset, maybe the instructor had dismissed it in the same way by not reading further on the TAF. The flight ran late an hour or more and because of this omission they ran into the weather. A major part of cross country navigation training should focus on the planning especially in regard to weather. It sounds like this was given a cursory glance and it caught them out.

[Lookleft]

One thing that might have been looked at a bit more closely was the weather forecasting.

Forecasting is a problem full stop. Too much reliance on computer modelling and not enough on local knowledge. Agree that the forecast for bad weather usually coincides with the onset of the bad weather.

[Squawk7700]

There are approximately 18 weather cameras between Warrnambool and and Avalon not inclusive too. I wonder if they used them or just flew into the crud unaware.

[43Inches]

A lack of weather awareness that also stands out is that the showers that grounded them in YWBL were heading East. The same showers would be between them and Moorabbin (and Cobden). Also there seemed to be lack of any real statement that they had much of a look around at the weather around YWBL on arrival. What was the weather looking like to the West, where prevailing weather was coming from on the day.

There are approximately 18 weather cameras between Warrnambool and and Avalon not inclusive too. I wonder if they used them or just flew into the crud unaware.

I agree, however I have been tricked by the cams at least once, where fog lifted, I looked at the cams and departed, only to find out it rolled back in shortly afterwards. No big problem, I was carrying fuel for a good alternate. Cams are a good tool, but use them with caution.

[megan]

Forecasting is a problem full stop. Too much reliance on computer modelling and not enough on local knowledgeTis said a report is a horoscope with numbers. Who hasn't been caught out with an erroneous report? Not knocking the met department, it's just the state of the art, I'm amazed at the work they do.

[deja vu]

Tis said a report is a horoscope with numbers. Who hasn't been caught out with an erroneous report? Not knocking the met department, it's just the state of the art, I'm amazed at the work they do.

Its a very long time since I flew in OZ and so I have no idea about cameras and accuracy of forecasting these days. Certainly back in the 70s/80s you could rely on a negative slant put on each and every forecast as a backside covering exercise. So many times offloading revenue stuff to carry 60 minutes holding only to arrive in CAVOK conditions. Better than the other way around I know. But it did lead to a state of mind suggesting it won't be "that bad".....boy....wolf ....type of thing.

[Squawk7700]

Tis said a report is a horoscope with numbers. Who hasn't been caught out with an erroneous report? Not knocking the met department, it's just the state of the art, I'm amazed at the work they do.

Ironically when I asked the BOM about my cameras, they said that they use them extensively.