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Sep02 Hamilton Is accident ATSB report

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Sep02 Hamilton Is accident ATSB report

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Old 18th Mar 2004, 05:28
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Sep02 Hamilton Is accident ATSB report

[QUOTE]At about 1708 Eastern Standard Time (EST) on 26 September 2002, the pilot of a Piper PA-32-300 (Cherokee Six) aircraft, registered VH-MAR, reported taxiing for departure from runway 14 at Hamilton Island, Queensland. The charter flight was to Lindeman Island, a distance of about 15 km to the southeast. On board the aircraft were the pilot and five passengers.

Witnesses to the east of runway 14 at Hamilton Island reported that, shortly after the aircraft became airborne, the engine began ‘coughing’ and ‘misfiring’, before ‘cutting out’ and then ‘starting again’. Shortly after, the aircraft commenced a right turn, and the engine was heard ‘spluttering’ and ‘misfiring’. Witnesses reported that, when part way around the turn, the engine again ‘cut out’, and the aircraft descended and impacted the ground.

The aircraft came to rest upright, aligned in an east-north-easterly direction, approximately 300 m to the west of the runway centreline and approximately 100 m south of the departure end of the runway. A severe post-impact fire consumed the majority of the aircraft’s fuselage. The six occupants of the aircraft were fatally injured.

The pilot was qualified, appropriately endorsed and authorised for the operation. The pilot’s condition and demeanour on the day of the occurrence were reported to be normal.

There was no evidence that fuel contamination, amount of fuel carried, structural failure or meteorological conditions were factors in the occurrence.

The engine installed in the aircraft was different from that specified in the aircraft Type Certificate Data Sheet. Notwithstanding, the Civil Aviation Safety Authority (CASA) and the engine manufacturer reported that the installed engine should have been capable of producing the power output expected from the engine certified for installation in the Cherokee Six. Furthermore, the engine had been in service in the aircraft for 126.2 flight hours with no reported power abnormalities, suggesting that, provided there were no defects, the engine should have been capable of producing the required power throughout its operating range.

The extensive damage caused by the impact forces and post-impact fire prevented functional testing of a significant number of aircraft and engine components. On the available evidence, there was nothing found to suggest what may have degraded the engine performance to the extent reported by the witnesses to the occurrence.

Post-mortem toxicological examination of the pilot’s blood revealed a blood alcohol concentration (BAC) of 0.081%, the presence of an inactive metabolite of cannabis, and an analgesic preparation consistent with a therapeutic dosage. The possibility that the pilot’s BAC reading resulted at least in part from post-mortem alcohol production could not be discounted.

There was insufficient evidence to definitively link the pilot’s prior intake of alcohol and/or cannabis with the occurrence. However, the adverse effects on pilot performance of post-alcohol impairment, recent cannabis use and fatigue could not be discounted as contributory factors to the occurrence. In particular, the possibility that the pilot experienced some degree of spatial disorientation during the turn as a combined result of the manoeuvre, associated head movements and alcohol-induced balance dysfunction could not be discounted.

The following factors were considered to have significantly contributed to the occurrence.

Based on witness reports, the aircraft’s engine commenced to operate abnormally shortly after lift off from the runway.
The pilot initiated a steepening right turn at low level.
The aircraft stalled at a height from which the pilot was unable to effect recovery.
The operator has initiated a number of safety actions in order to mitigate some of the issues identified in the report. Those actions include the areas of: company pilot training, fatigue management, documentation, and aircraft operations.

The ATSB has issued four recommendations concurrent with the release of this report. The first three recommendations address the potential use of alcohol and drugs by safety-sensitive personnel in the Australian aviation industry, and options to manage the safety risk to the travelling public of that potential use. The fourth recommendation addresses the CASA Air Operator Certificate Safety Trend Indicator surveillance methodology. In addition, two Safety Advisory Notices have been issued to CASA relating to pilot manipulation of the Cherokee Six fuel selector and development by operators of pilot induction training programs. [QUOTE]

Full report
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Old 18th Mar 2004, 05:52
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"Post-mortem toxicological examination of the pilot’s blood revealed a blood alcohol concentration (BAC) of 0.081%, the presence of an inactive metabolite of cannabis, and an analgesic preparation consistent with a therapeutic dosage. The possibility that the pilot’s BAC reading resulted at least in part from post-mortem alcohol production could not be discounted".

What the hell does that mean, 0.081 post mortem, isn't that terribly high ?.
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Old 18th Mar 2004, 06:51
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The pilot’s blood alcohol concentration (BAC) was found to be 0.081%. However, the examining toxicologist stated that, due to the possibility for post-mortem production of alcohol, that result should be interpreted with caution.
Even with that, it's still quite a concern. And what about Cannabis use? Another ATSB report dealing specifically with the effects of cannabis use on pilot performance states;
…there were significant effects on pilot performance 24 hours after smoking a single marijuana cigarette. Overall, the pilots demonstrated much more difficulty in aligning with and landing on the runway after 9-THC exposure. There were increases in the number and size of aileron changes, the size of elevator changes and the degree of vertical and lateral deviation from the required flightpath during the approach to land. At 24 hours post-marijuana, the lateral deviation on approach to land was almost twice that of the pre-marijuana test.
Granted the post mortem result on this particular incident was only able to say the inactive metabolite of THC was present suggesting that cannabis was used within the previous two weeks. But it's still interesting to note that even while not experiencing a "high" you can still be effected by the drug.
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Old 18th Mar 2004, 08:00
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Angry

And in typical Australian fashion, the "no nothing public" throw their arms in the air and want pre flight drug and alcahol testing.
And how many tax payers dollars are going to be spent now in the process of enquiring as to whether this is a viable option. people that know nothing of aviation (read politicians) sitting around discussing at graet length, how we are all drugged up drunks, and how they can stop the public from embarking on a trip with a drunk pilot. Better they should concentrate on the roads until they have that problem sorted in my opinion.
You just have to love the fact that anything that involves aircraft in australia negativley, has a huge knee jerk reaction attached to it.
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Old 18th Mar 2004, 08:50
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Grrr

I think that the ATSB absolutely slammed this bloke in a disgusting way. This Accident occurred in the afternoon. I spoke to him at 21:00 EST the night before and he wasn't showing signs of intoxication. I don’t doubt that he had a few beers the night before but to have an 0.0.81% at 17:00 the next day is highly unlikely considering
The pilot’s condition and demeanour on the day of the occurrence were reported to be normal.
To have a blood alcohol limit at this level, that late in the arvo he would have to have shown some signs of severe illness during the day. To my knowledge having smoked pot within the two weeks prior would have had negligible effect on his decision making. Talk about digging up crap. The important question is to ask why the engine quit!

What alarms me is the fact that on the news they did not mention the fact that the engine quit on him in a loaded up Cherokee six on a hot day. The ATSB and the media have NO RESPECT for a good man that was placed in a awful situation and directly in harms way.
There was insufficient evidence to definitively link the pilot’s prior intake of alcohol and/or cannabis with the occurrence.
If the evidence isn’t there that the BAC directly attributed to the crash, then dont disrespect a good man. As they say easy to blame the dead guy because he cant be there to defend himself/herself.

The ATSB should take a bow for being W#%nkers and the media, we all know that the pressure of whatever sells the papers or ratings will win over respect for our deceased and unfairly blamed colleagues.

As for the Preflight breath test, I’ve got nothing in principle against it but if it does go through, then I hope it isn’t used as a mechanism to terminate a pilots employment. Yet again when the Pollies jump in and stick up their dirty paws for pre parliament breath testing then there will be a level playing field. Standard that there is a double standard.

Sad day for the industry and respect to a deceased mate
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Old 18th Mar 2004, 09:44
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Heya Shmoo, long time no speak. From my limited understanding of things medical I interpret some of what has been said about Andy's BAC in the report as a phenomenon which apparently causes any alcohol that may have been stored in his muscular and fatty tissues to leach into what was the bloodstream after his accident.

He may well have only had a couple of 'full strengths' the night previous?

Can anyone shed any more light on
....The possibility that the pilot’s BAC reading resulted at least in part from post-mortem alcohol production could not be discounted....
?????

As far as the rest goes, how is it any different to someone getting into a car and driving in the same (supposed) state? Thye potential for causing death and damage is just as high.

RIP Andy.
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Old 18th Mar 2004, 10:13
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However, the examining toxicologist stated that, due to the possibility for post-mortem production of alcohol, that result should be interpreted with caution.

I have NO medical training but I do have a memory.

Prior to PNG Independance (1975!) TAA amongst others operated domestic flights in the then TPNG. A TAA Twin Otter crashed in inaccessable bush (I think between Hagen and Goroka) and it was some days before a ground party reached the aircraft. During the post mortem of the crew, alcohol was detected. To cut a long story short, the crews family's and the AFAP sought further tests, ultimately proving for the first time I believe, how to detect the difference between induced alcohol and that produced when blood sugar ferments (in a body).

As with all accident reports, one should read the ENTIRE report and not try to precis it. This is of course where those members of the press fall flat on their faces when they try to fill 30 seconds on the 6 o'clock news.

Read this report again, you will find a number of clarifications regarding the alcohol matter, including 'suspect' or damaged blood samples.

Disco Stu
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Old 18th Mar 2004, 11:08
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TN Twin Otter accident was near Kainantu
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Old 18th Mar 2004, 12:11
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People trying to cover their arses and ATSB helping the media in their quest to beat us down....

aaah you gotta love this industry
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Old 18th Mar 2004, 12:24
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The important question is to ask why the engine quit!
Well **** happens..it's how you deal with it that counts..sorry for being blunt!
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Old 18th Mar 2004, 12:31
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Angry

I'm now aware of this phenomenonn of post death BAC rising, cheers. But surely the people involved are coroners and the like, at some stage of the process. Surely this phenomenon wouldn't be lost on them and therefor why drag this poor guy through the mud and slander his name and his memory unnecessarily. I just think it is extremely disgusting to a good mates memory. If it is not directly involved and can be attributed then leave it out. That bit about smoking pot within 2 weeks prior is in breech of his privacy and indeed had he been alive surely he could claim defamation. This is generally directed towards the media's portrayal of the event which has been recounted by non aviator friends and family as pilot was on pot and blind drunk at the time of the crash.......................Well I hope that they sell lots of papers tommorrow, and the TV ratings were worth it. My feelings go out the Andy's family, who should be ropable at the abhorrent portrayal of their late son.

RIP mate
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Old 18th Mar 2004, 12:41
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Let's not automatically shoot the messenger, people, no matter how noble your intentions. They are there to provide basic facts, and they have done that. Naturally any mention of alcohol or cannabis, or even better, both at once, will cause the media to jump on it; what do you expect? A BAC of 0.08 at 5pm takes a bit of explaining. But everybody here has cottoned on to that incredible sentence...
The possibility that the pilot’s BAC reading resulted at least in part from post-mortem alcohol production could not be discounted.
That was news to me and to everybody I have spoken to in aviation about this report. Captain Marvellous apparently knows all about it, perhaps he can explain it to us. It will save me Googling it myself if he does it for us. I don't mean to sound as though I doubt it, it's just completely foreign to me and I'm happy to admit it.

I was working at Hammo when the preliminary report came out about six weeks ago and the alcohol and cannabis reference was the main talking point of the flying community up there at that time as it has the media's attention now. It would be unnatural for it not to.

The report as issued is one of those things which, while factually based, is going to leave a slur for all time on the pilot whatever the truth. I can only say that the general attitude up there at the time was not one of "Oh yeah, well it had to happen to him eventually." More so it was disbelief, and with good reason. This accident happened at the end of what was a pretty normal hard day for these guys; starting early, multiple short legs in hot sticky conditions, loading and unloading baggage all day.

As one pilot said to me, if anybody had consumed enough alcohol to be still reading .08 at the end of the day, he would have been absolutely reeking of it earlier. Even in the unlikely event that no passenger in the cramped confines of a PA32 reported him smelling of alcohol on a normal day, once news of the accident was released passengers would have been crawling out of the woodwork to get their faces on the news to tell their story. No such stories exist.

This alcohol thing doesn't add up and I hope for the sake of the dead pilot's reputation and the peace of mind of his passengers, the post-mortem alcohol production is addressed more clearly than just a footnote in the report. Let's hope that when it is, the media will be as keen to jump on it as they have been to jump on their earlier reports.

RIP Andy.
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Old 18th Mar 2004, 12:51
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On Wed night before the release of the report the ATSB put the following out on their "Latest Releases" email list:

MEDIA ALERT - Release of ATSB final investigation report on the Hamilton Island fatal aircraft accident and research papers on alcohol and cannabis use. http://www.atsb.gov.au/atsb/media/alert35.cfm

Hardly suprising the media was OTT today, they have had plenty of time to get ready.
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Old 19th Mar 2004, 00:06
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Well **** happens..it's how you deal with it that counts[/QUOTE]

very arrogant statement to make....let's just hope you don't find yourself in a similar situation, if you already have... well done and more experience to you
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Old 19th Mar 2004, 00:52
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Before to many of you embrace the prospect of Pre-flight breath testing, consider this. It may not be the test itself that may cause you problems, but the skill (or lack of) or interpretation of the Human Tester. Do you have faith that those appointed to carry out these test's will be paid for, and have the very highest of qualifications available that you and your Licence deserve, or will it be Low cost testing with an acceptable margin of error. Inevitably hurriedly introduced, using half-thought measures and potential mistakes.

We have all read and heard about erroneous breathalyser test's applied to Motorists, imagine this same/similar style of testing when your career is directly "on the line". The implications of this are far reaching and a little more serious than "sounds OK to me"

If you disagree, see above how facts can be manipulated when one has an agender to fullfill.
 
Old 19th Mar 2004, 01:02
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I think that a lot of you are missing the point here. There was a horrible accident, the ATSB investigated it and found what they found. It is public information and it was released to the media who reported it.
That facts are that they found a high level of alcohol and some grass in the pilot's blood. The media reported that fact. The public hear it and read it and interpret it their own way. The same way that you guys and girls would read it if you were not pilots. Comments like those made on air by AOPA president Ron Lawford do not help much. Ron resists drug and alcohol screening as he feels that pilots have "too many constraints" placed upon them already. The public see this as the industry not listening to good advice. AOPA need a more media savvy spokeperson I think.
Let's not also forget that many pilots are out flying today with massive hangovers and drugs in their system. They should probably not be there as they are judgemnt impaired. Pilots laugh about these stories all the time. Get real guys.

The ATSB and the media did their job correctly. If you want public perception to change then it starts with pilots smartening up to life outside our cozy cockpits. Keep it in perspective.

GJ
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Old 19th Mar 2004, 06:29
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That facts are that they found a high level of alcohol and some grass in the pilot's blood. The media reported that fact. The public hear it and read it and interpret it their own way
Lets see....

The ATSB inquiry into the crash that killed an entire New Zealand family and a newly married American tourist, while his wife watched on, has found that the pilot had both alcohol and cannabis in his bloodstream. This has prompted calls for random alcohol and drug testing for all pilots.

or

The ATSB has been unable to determine the reason for the engine failure that resulted in the death of six people in a Hamilton Isand air crash.

The finding of traces of alcohol and cannabis in the pilot's bloodstream may well have been the result of post-mortem reactions within the body, the report noted. Witnesses reported that, in the 24 hours leading up to the accident, the pilot did not appear to be affected by either alcohol or drugs.


Which version do you prefer?
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Old 19th Mar 2004, 06:36
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The ATSB would have to be acutely aware of not stating anything as a fact ( or suggestive, ie "he was on the piss at lunch time" ), all that is being said the way i read it is that his BAC was high, and quite a bit higher than they would expect given the environment ( ie the "in part" bit).

Again it would appear emotion is getting in the way of the evidence, never has anybody suggested he was anything less than a great bloke.

Is it suggested that any possible combination of Panadene, Hooch or Alcohol could have not reduced his capacity to safely operate this aircraft ?.
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Old 19th Mar 2004, 06:41
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Firstly I would like to say that yes it was a very sad thing to happen as I was not far off witnessing it myself. As I watched the flames die down and flew past the wreck it sent complete shock through my body to see a company aircraft in flames.

Gin jokey I agree with to some point that the media did do their job but the general public percieve things to the most extreme with almost anything to do with aviation which has been reported by the media. I do not know what I think about breath testing and at the end of the day i have no real say.

The general public only listen to the key words and develop this image in thier minds. eg, A/C crashes, pilot found drugs and alcohol in his system and pharmacy drugs in his system.

Maybe the guy had a few drinks the night before and at some stage used weed, the next day he has had a hang over and head ache and then taken something to fix that. Not saying by any means that that is what Andrew did ! who knows. The report also is not conclusive on whether the A/C was stalled to make it turn on wing drop or he tried to turn it back and make the field .

However I did not expect the toxicology report to to be like it was nor that from him. But I also only knew him for a short time.

Just a few thoughts. You can discuss what made him do what he did for ever but no one else was on the A/C to testify.

Safe flying to all
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Old 19th Mar 2004, 07:34
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Lets say for example (if said drugs and alcohol had zero to do with this accident) that a pilot had at some time been treated for an emotional trauma. Would it be relevant then to raise this also in the report ie "Pilot Bloggs had recieved psychiatric treatment in the past". Was the info given relevant?
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