Mount Gambier CFIT and single pilot IFR.

[Menen]

The RFDS King Air Mount Gambier ATSB report is out. Well written as always, but leaves you wondering how a 13,000 hour pilot can get himself in such a situation on a dark and misty night that he drives it in three miles short of the runway at between 15-2800 feet per minute rate of descent - or put another way, four times steeper than a typical ILS glide slope angle. Would a second pilot in the cockpit have picked up the dangerous rate of descent and obviously low altitude? Most probably. Would that have prevented the accident? Most certainly.

The ATSB report discusses in general the flight safety aspects of single pilot dark night non-precision approaches, adding that the use of two pilots is a means of providing greater safety. The report then backs off by stating that the cost of implementing two pilot operations can be prohibitive for a small operator.

How does one define a small operator in GA? Two aircraft or maybe three? With many state governments demanding a two pilot crew for employee travel, as well as countless other firms including mining companies, going down the same route - (all for proven safety reasons) then how many of these operators have gone broke simply because they are contracted to use two pilots? Very few I would bet. Is the RFDS a small operator by ATSB standards? Not really.

Then why doesn't the RFDS wake up to reality and read and absorb all the warnings of single pilot CFIT risks. The pilot of the Mount Gambier accident was highly experienced, had a fine safety record, but that night was dog-tired and all on his own. His planned single pilot duty times for that day and night was maybe just legal - but at night on an urgent mission, demonstrably damned unsafe.

The RFDS attitude is hairy chested and hasn't changed over the years. Our pilots are the best - we can serve the community in all weathers with only one pilot at the helm - all the others are wimps. Tell you what - one never hears of the close shaves experienced by the RFDS pilots at night in the outback - but I bet they have tales to tell. All kept in-house, of course.

As always, our safety regulator looks the other way. After all, only one person was killed and a few bushes knocked over. No need to rock the regulatory boat.

[olderbutyzer]

one never hears of the close shaves experienced by the RFDS pilots at night in the outback

Exactly. And even though this particular accident was in a twin engined aircraft, I am more concerned about operating the singles they now have at night into some of the outback areas. I am not talking about ALA's here either, but more the landings at some remote station or settlement & the distances flown from their nearest base.

[Menen]

Now here's an interesting coincidence.
Just received in the mail an appeal for money for the RFDS, from Bud Tingwell, Victorian President of the RFDS. The blurb on the cover says:

"Today, over 45 doctors, 115 nurses and 95 pilots will be involved in evacuating at least 75 people including 25 accident and emergency flights, conducting 24 medical clinics in remote outback Australia, and flying more than 46,000 kms to attend to patients anywhere between Christmas Island in the Indian Ocean and Lizard Island on the Great Barrier Reef."

If I recall, Bud Tingwell was a wartime pilot. He should know all about CFIT - there were a lot in those days. What about two pilot crews for the RFDS, Bud?

And inside the envelope in which to send your donations, there is another bit which says that in WA alone there are eleven RFDS aircraft. So add a few more aircraft in each of the other States and you have a lot of RFDS aeroplanes all flown single pilot IFR.


From these figures one can deduce quite confidently that the RFDS is not exactly one of ATSB's small operators that will go to the wall if they employ two pilot crews.

[nzer]

I have made a close study of CFIT incidents (IE, "near" CFIT's with "escapes") and CFIT accidents over some time, and while I agree personally that certainly night ops at least should have x 2 pilots, there is no statistical link between crew composiion and CFIT/reduction thereof. Please do not take from this for a minute that I am not endorsing the multi-crew conept for RPT operations - being from NZ, I am not sure what classification of operation the RFDS is under CASA Rules? - But by the same token we have to lok past the SPIFR issue - how about mandatory installations of GWOPs/GPWS/ etc, more ILS installations - (5 times lower chance of a CFIT/Approach accident on an ILS than an NPA) and so forth.

[otto the grot]

This accident has brought some very contentious issues out in the open.

I agree with all of the above however:

With the B200 and PC12 being the aircraft of choice for this operator (for some very good reasons), adding a second pilot to an already very high operating weight due medical fit out would restrict even more, the limited loads these a/c could usefully carry.

There must be an alternative. Why not adopt the best available technolgy. ie. EGPWS, TCAS2, and fully integrated FMS with moving map display. Expensive? Yes. But the consequences of continuing without these systems are more so, not only in dollars, but lives.

The other very relevant issue here is the lack of policy established by operators, government departments, crew members unions etc. to restrict the number and types of flights to be undertaken by pilots to poorly serviced aerodromes during night time ops. And by poorly serviced I mean no approach what so ever and the use of portable lights or flares on the landing strip.

Although the pilot at MTG had only done 4 sectors it is likely that the first 3 were non-urgent and unnecessary. Non-urgent routine transfers should be scheduled for daytime only shifts. This is currently not the case.

[ITCZ]

There is certainly scope to discuss the RFDS and it operations after this accident, but I think some of you guys are just jumping in and kicking them while they are down. Not very helpful.

Menen - The RFDS attitude is hairy chested and hasn't changed over the years. Our pilots are the best - we can serve the community in all weathers with only one pilot at the helm - all the others are wimps.

Where on earth did you get the idea? RFDS pilot nick off with your girlfriend maybe? Not the stuff to really enhance a safety argument, sweeping generalisations like that.

Many RFDS people were regarded in the Territory as being a bit 'soft' and afraid of a bit of weather. Now, whose sweeping generalisation wins, yours or mine? Get a grip son.

[Jet_A_Knight]

Without having digested the whole report, it seems to point toward pilot fatigue being a significant factor.

4 nights in a row on duty is too much, I believe.

As stated previously, there is a valid safety case for multi crew operations, but this in itself has not, or does not, prevent CFIT 'events'.

More attention needs to be paid to aspects of flight crew rostering practices, as well as duty periods and times that those duties occur. This may include some time to adjust between, or adapt to, night ops then day ops, as well as LATE night ops/day ops etc, and vice versa.

For example, progressively rostering from say day ops, to afternoon ops, to night ops, to late night ops with succeeding rosters, then reversing the roster progressively back to day ops. This give a slow adaptation over time for the body to adapt and re adapt to changing. Unfortunately, this does not always coincide with an organisations' requirement for the economically efficient utilisation of flight crews.

Therein lies the dilemma - safety versus economics - or a compromise between the two? How could/should a comprimise be made?

[Menen]

ITCZ. Fair enough comment. Could have been better phrased.

Jet-A-Knight. Sensible rostering of night shifts is important, as you point out. Fact remains that there is no shortage of evidence that a two pilot crew in the environment that requires remote area night non-precision approaches, is certainly a safer option that a single pilot IFR policy, regardless of all the warning bells and whistles in the aircraft. A lengthy chapter on this very subject is included in the ATSB report on the Mt Gambier accident.

Given the choice of being a patient/passenger strapped onto a stretcher on a dark and stormy night in an RFDS aircraft flown by one pilot and no one else up front - or the same aircraft with two pilots up front - I know which I would choose.

[Iceman Rocks]

I agree with MENAN

[Jamair]

OtG: There is no distinction between 'classes' of mission; the flights are rated as 'go' or 'no-go' based solely on the normal operational imperatives - weather, range / load, alternates etc. Although the ATSB report noted that this flight was 'time critical', that is not an issue in the planning or conduct of the mission - in most aeromedical systems, the nature of the mission is not expressed to the pilot, all they get is "can we?".

Although the pilot at MTG had only done 4 sectors it is likely that the first 3 were non-urgent and unnecessary. Non-urgent routine transfers should be scheduled for daytime only shifts. This is currently not the case. If they had been accepted, then a clinical coordinator had deemed them necessary.

For what it's worth, I also believe that complex aircraft ops in less than VMC should be multi-crew, but B200 aeromedical aircraft simply don't have the capacity to spare. I also believe (my opinion) that it's time for RFDS to move from their current parochial State-based operations to a truly National organisation, in reality not just in name, and coordinate their standards and systems. For example, why hadn't this branch of the RFDS embraced the latest available navigational and systems technology? This B200 was equipped but not certified, and the pilot wasn't approved, to conduct a GPS NPA.

This ATSB report - like other applicable reports - will go into the mental filing cabinet in the back of my mind to be flagged every time I start setting up for a dark night approach, and if we all adopt the same philosophy, then that may save a few more in future. 'Those who do not learn from the mistakes of the past are doomed to repeat the same mistakes in the future'.

[otto the grot]

G'day Jamair.

Look, you have some valid points and I agree with the fact that the clinical decision has been made and that, ideally, the only decision placed on the pilots is weather, range/load, alternates etc. But it is not a perfect world and the ideal situation is quite often far from reality.

Controllers that make the clinical decisions on these jobs can be influenced by many factors. The most annoying of which is the flow of missinformation fed to them by many of the hospitals that, for whatever reason, want to empty a bed regardless of the patients condition.

It's been pointed out to me on many occasions following a job that the patient could have been moved the next day. Many of these patients, by the way, hop out of the front seat of an ambulance at the airport and nimbly walk up the stairs into the aircraft. Meanwhile the controllers back at base are pulling their hair out because they have a genuine urgent job that they haven't got a crew or aircraft for.

The lack of decision making ability by the country doctors is a major factor aswell. All too often, patients that present to the hospital in the morning or early afternoon with obvious conditions, are held for many hours before the call to move them by air is made in the early hours.

This is what I'm reffering to Jamair. The operational decisions made by pilots go without saying. Just get rid of the politics and lack of communication and we're one step closer to a perfect world.

Urgent jobs should be seen to in the middle of the night. Thats what these services are here for. But remember, the non "time critical" jobs that are often requested at these times can also go by road in many states, leaving the aircraft on standby. Apart from remote area retrievals, moving a patient by air is not the only way available. Even critical jobs go by road if the weather is too bad.

The operational decision by pilots can also be factored here. Sure the conditions may exist where a simple approach in bad weather will result in a safe circle to land. Completely legal and totally doable. Sh!t night freighters do it all the time. The pilots decision to go could be very reasonable. But why send an aircraft in these conditions at night if it is not necessary.

If two pilots are deemed necessary then great. If greater technology is introduced to the cockpit. Brilliant. But sorting out the mess I've just outlined will go a long way to a safer operation aswell.

[Jamair]

OtG - G'day again. We are in heated agreement on several points; BUT the issue of 'roading' patients (in the rural and remote environment) is one of last, rather than first, resort.

In the areas you speak of (and you seem to speak with knowledge) sending a non-urgent patient by road may keep the aeromedical resource available for the 'real' work, but it actually removes what is often the only ambulance resource in the area for many hours. (and hands up all those sick poeple who would prefer 4-5 hours in the back of a 4 ton hard-sprung truck, rather than an hour in an aeroplane.)

Remember too that 99.98% of aeromedical cases are retrievals from regional hospitals, not the 'mercy dash' to some remote outpost; so when the injury or medical emergency occurs, and the only ambulance with 10,000 square km is doing a non-urgent road transfer - who attends to the accident or emergency to get them TO the regional hospital? (while they're still alive). Recovery FROM the regional centre is less urgent than getting them there to start with.

It is generally a relatively simple matter to find another aircraft for the urgent retrieval - the time variance from tasking from other than the nearest base of ops is seldom more than an hour or two tops - but it is entirely another matter trying to get an ambulance from the next available area, which apart from taking up to several hours to get, then also leaves THAT area unattended. (remember I said relatively).

There is a solution that addresses the issues raised in this forum as well as issues underlying the management of aeromedical services in this country generally - that solution is to take the whole charity based concept of RFDS and BIN it; then properly fund a national service which has sufficient resources in both aircraft and crew to manage the workload based on a genuine analysis of needs from a properly structured study. Until then, we will continue to suffer the frustrations of a less than ideal aeromedical service and we will continue to see the results of issues such as that identified by this ATSB report.

Cheers

[otto the grot]

No arguments with you on this one Jamair. Roading a patient does tie up the only resource in an area for far too long as you said. Another of the factors influencing the controllers decision.

So lets just put the whole thing off until daylight hours and reserve back of the clock stuff for "time critical". Everyone bar the country hospitals are happy and the non urgent patients get a few more hours shut eye with a nice wholesome breakfast before their journey. :zzz: :yuk:

[Captain Custard]

Also of interest were the two sets of Tx he made to activate the PAL (the second attempt 4 minutes before impact): he was obviously unsure that his first attempt was successful, so had another go. Had MTG been equipped with PAL+AFRU, he would have had immediate confirmation that he had turned the lights on the first time, which would have saved time and workload.

All these little things reduce workload, stress and therefore improve safety, and may be the straw that breaks/broke the camel's back if airports are not fitted with them.

[Northern Chique]

I agree with Jamair...

Roading a patient, even a non crititcal one, can further influence the patients outcome... even something non critical can turn critical... and believe me... not many of you would put up with me for 4 plus hours locked in the back of a bouncing mercedes ambulance or troupcarrier....

Our very meger resources cannot support doing clinic runs out of town, that is primarily left to the hospital plane.

Our total area covered is Barkly to Barrow Creek, to the WA border to Elliot .. square the miles up and its a huge area to cover with one ambulance.

As a result we do alot of work with the RFDS and our Hospital plane... it seems to be an efficient use of available resources given the area we all cover.

Still, with the demand, there never seems to be enough people, planes, doctors and cars when you need them the most. It all comes down to the bean counters and the parameters they define...

We fought to keep our plane, and fought hard. And those who did the fighting know who they are... If want want something badly enough, go knock on the right doors and suggest, tell, demand... legislate if you have to.... but until the fatigue problem / multicrew suggestions etc are addressed on a mass scale nothing will happen except the possibilty more talented lives with join those already lost to us.

[Col. Walter E. Kurtz]

CC - Who's never clicked the PAL more than once??

[otto the grot]

G'day Northern Chique,

Nice to have the NT perspective on this.

Roading patients obviously is'nt the prefered option but at night that is sometimes all there is and in my opinion, the safest option at these early hours if non urgent.

My argument here is that night ops should be limited to emerg only. If the hospitals really want the non-urgent patients down to the city at 2 or 3 in the morning, they need to either get their act together and move them by air the day before (beds prevailing) or move them by road at 2 or 3 and leave, in many cases, the 1 and only aircraft and pilot to cover emerg only jobs. This avoids having to unnecessarily fly multiple sectors on dark unfriendly nights when he/she is naturally tired.

This sort of policy may have seen a different outcome at MTG.

[Captain Custard]

Colonel,

That's my point. Airport owners should change their PAL systems over to the PAL+AFRU system pronto to reduce workload and anxiety on crews. You do know what PAL+AFRU is don't you?

Not being an RFDS pilot, but noting what I have read here and on the Coffs Harbour thread, it seems to me that these flights are pretty tough stuff and should have 2 crew. Period. RFDS is at least partially funded by the taxpayer, and I'd reckon they would agree to paying a bit more for an extra driver. I certainly do. Dick Smith would also agree: more jobs for pilots! Maybe that's where the $70m that NAS is going to save could go....

[Col. Walter E. Kurtz]

CC - Yes I do know what they are.

Good idea - just misread your post!