Preliminary report VH TNP
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No alert by ATC as plane flew off course
http://www.theaustralian.news.com.au...E23349,00.html
No alert as plane flew off course
Steve Creedy, Aviation writer
September 16, 2004
AIR traffic controllers received two alarm signals indicating a plane that crashed killing six people earlier this year was off course, but did not tell the pilot, The Australian has learned.
The twin-engine Piper Cheyenne Aircraft spent a substantial part of its journey from Sydney off course and arrived near Benalla, 200km northeast of Melbourne, 34km southeast of the airfield at which it was attempting to land in stormy weather,
Sydney chip-board company executive Robert Henderson, his daughter Jacqueline, RAAF helicopter pilot Alan Stark, Belinda Andrews, Qantas pilot Geoff Brockie, and the Cheyenne's pilot, Kerry Endicott, died when the plane hit a mountain. The role played by air traffic control is understood to be one of several issues of "possible safety significance" being probed by an Australian Transport Safety Bureau investigation.
Airservices Australia is also conducting an internal investigation that includes the monitoring procedures used by the air traffic controllers.
An Airservices spokesman would not comment on the issue other than to say the accident was still being investigated. But sources confirmed air traffic controllers received warnings from a route monitor, an in-built alarm that goes off when an aircraft is not following the correct flight path.
It is understood controllers acknowledged the route-monitor alarms according to procedures, but did not believe it necessary to contact the aircraft.
Sources suggested the deviation may have been within the air traffic control system's tolerance or that the controllers believed it was happening because the aircraft was headed for a southerly global positioning system approach point rather than a northern point, for which it was originally cleared. Mr Endicott was a highly experienced pilot but that day followed a different route from Sydney's Bankstown Airport to the one he normally took.
Instead of flying directly to Benalla, he followed the coast to Jervis Bay, south of Sydney, and then asked air traffic controllers for a track to Benalla using the GPS for navigation. According to a preliminary ATSB report, the aircraft was consistently 3.83 degrees left of the direct track from Jervis Bay. The route did not pass over ground-based navigation aids and Mr Endicott relied on the GPS for his approach to Benalla.
Investigators found the pilot told air traffic control at 10.45am he was starting a GPS approach and the alarm was raised 18 minutes later when he failed to report he had landed. The aircraft hit trees on a hillside with its wings level and landing gear and flaps extended, suggesting the pilot believed he was landing at Benalla.
The ATSB expects to issue an interim factual report by February and the accident will also be subject to a coronial inquest.
No alert as plane flew off course
Steve Creedy, Aviation writer
September 16, 2004
AIR traffic controllers received two alarm signals indicating a plane that crashed killing six people earlier this year was off course, but did not tell the pilot, The Australian has learned.
The twin-engine Piper Cheyenne Aircraft spent a substantial part of its journey from Sydney off course and arrived near Benalla, 200km northeast of Melbourne, 34km southeast of the airfield at which it was attempting to land in stormy weather,
Sydney chip-board company executive Robert Henderson, his daughter Jacqueline, RAAF helicopter pilot Alan Stark, Belinda Andrews, Qantas pilot Geoff Brockie, and the Cheyenne's pilot, Kerry Endicott, died when the plane hit a mountain. The role played by air traffic control is understood to be one of several issues of "possible safety significance" being probed by an Australian Transport Safety Bureau investigation.
Airservices Australia is also conducting an internal investigation that includes the monitoring procedures used by the air traffic controllers.
An Airservices spokesman would not comment on the issue other than to say the accident was still being investigated. But sources confirmed air traffic controllers received warnings from a route monitor, an in-built alarm that goes off when an aircraft is not following the correct flight path.
It is understood controllers acknowledged the route-monitor alarms according to procedures, but did not believe it necessary to contact the aircraft.
Sources suggested the deviation may have been within the air traffic control system's tolerance or that the controllers believed it was happening because the aircraft was headed for a southerly global positioning system approach point rather than a northern point, for which it was originally cleared. Mr Endicott was a highly experienced pilot but that day followed a different route from Sydney's Bankstown Airport to the one he normally took.
Instead of flying directly to Benalla, he followed the coast to Jervis Bay, south of Sydney, and then asked air traffic controllers for a track to Benalla using the GPS for navigation. According to a preliminary ATSB report, the aircraft was consistently 3.83 degrees left of the direct track from Jervis Bay. The route did not pass over ground-based navigation aids and Mr Endicott relied on the GPS for his approach to Benalla.
Investigators found the pilot told air traffic control at 10.45am he was starting a GPS approach and the alarm was raised 18 minutes later when he failed to report he had landed. The aircraft hit trees on a hillside with its wings level and landing gear and flaps extended, suggesting the pilot believed he was landing at Benalla.
The ATSB expects to issue an interim factual report by February and the accident will also be subject to a coronial inquest.
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Crux of the matter
If the aircraft was being navigated by GPS, as the primary means of navigation, they should have known they were off course.
Why did the GPS lead them astray? This is a line that has received no mention.
Why did the GPS lead them astray? This is a line that has received no mention.
muddergoose,
Bit of a leap to say the GPS took them off course....mode awareness has caught many people out, nav source selection (GPS/NAV/OBS), autopilot mode etc (HDG/NAV), far too many factors to speculate on...another sad loss.
I await to see with interest what the professional investigations come up with.
Bit of a leap to say the GPS took them off course....mode awareness has caught many people out, nav source selection (GPS/NAV/OBS), autopilot mode etc (HDG/NAV), far too many factors to speculate on...another sad loss.
I await to see with interest what the professional investigations come up with.
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Folks,
If we had had the US NAS system in place, this accident would not have happened.
If it wasn’t for all the resistance to the US system, it would have been it in place.
It would have been called Airspace 2000, or perhaps (the original) LLAMP, (not the final LLAMP abortion that was mercifully interred).
Even if we had had flight following in place, which is part of the US NAS, and intended for the Australian NAS, and can be done now, this accident would have been extremely, and I mean extremely, unlikely.
TAATS has all the capabilities needed to provide these services, right now.
Many controllers are doing the right thing, and using their noggins, in fact maybe sticking their professional necks out, and providing services that are beyond the “average”, or those services required to be provided.
This to aircraft visible to controllers, that would obviously benefit from proffered advice and/or assistance, regardless of the class of airspace.
We all thank those controllers who go the extra mile, but that is all dependent on rather fluffy “workload permitting” rules interpretations, a moveable feast.
The NAS would have/ will provide E airspace protection right down to the approach ( 1200/700 AGL) at places like Benalla, and in the Center, should provide automatic terrain alarms, off cleared track alarms (as seems to have been activated, but not acted upon, in this dreadful accident) as well as human monitoring.
This accident is a wakeup call, it’s a real shame that it seems to take an aviation disaster to get progress, but look at history, that’s the Australian way.
The disaster has happened, let’s get on with it.
The Dwarf
If we had had the US NAS system in place, this accident would not have happened.
If it wasn’t for all the resistance to the US system, it would have been it in place.
It would have been called Airspace 2000, or perhaps (the original) LLAMP, (not the final LLAMP abortion that was mercifully interred).
Even if we had had flight following in place, which is part of the US NAS, and intended for the Australian NAS, and can be done now, this accident would have been extremely, and I mean extremely, unlikely.
TAATS has all the capabilities needed to provide these services, right now.
Many controllers are doing the right thing, and using their noggins, in fact maybe sticking their professional necks out, and providing services that are beyond the “average”, or those services required to be provided.
This to aircraft visible to controllers, that would obviously benefit from proffered advice and/or assistance, regardless of the class of airspace.
We all thank those controllers who go the extra mile, but that is all dependent on rather fluffy “workload permitting” rules interpretations, a moveable feast.
The NAS would have/ will provide E airspace protection right down to the approach ( 1200/700 AGL) at places like Benalla, and in the Center, should provide automatic terrain alarms, off cleared track alarms (as seems to have been activated, but not acted upon, in this dreadful accident) as well as human monitoring.
This accident is a wakeup call, it’s a real shame that it seems to take an aviation disaster to get progress, but look at history, that’s the Australian way.
The disaster has happened, let’s get on with it.
The Dwarf
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Little plane lost - six deaths, no reason
By Robert Wainwright
September 17, 2004
Two Melbourne air traffic controllers have been stood down after preliminary investigations into the death of six people aboard a plane which crashed on a flight from Bankstown to the Victorian town of Benalla two months ago.
The fallout from the tragedy is set to reignite a verbal war over aviation safety as the Federal Government prepares to overhaul the way air space is managed.
Inquiries by the Herald have revealed that Airservices Australia board members discussed the crash a month ago, including detail that the pilot, Kerry Endicott, was not warned on three occasions that he had drifted dangerously off course on the Ulladulla-Benalla leg of the journey.
By the time the plane reached the crash site an hour later, it was 12 kilometres south of the check- point Mr Endicott thought he was heading towards.
He had been flying in cloud cover and rain that made it impossible to realise his error. When he banked left to prepare to land, the Piper Cheyennecrashed into mountainous countryside, killing all on board instantly.
The families of the victims spoke yesterday for the first time since the July 28 tragedy. They are concerned about time it will take authorities to finish their investigations and potential safety problems for others in the meantime.
David Henderson is mourning his brother, businessman Robert Henderson, and niece, Jacqui Stark. They died along with Jacqui's husband, Alan, his friend Geoff Brockie, Belinda Andrews and Mr Endicott.
Mr Henderson said the preliminary report from the Australian Transport Safety Bureau made it clear the plane crashed because it was off course and that Mr Endicott, an experienced pilot, punched the wrong co-ordinates into GPS equipment.
However, they do not know why the plane was allowed to veer almost four degrees from its designated flight path, through controlled air space for hundreds of kilometres between Ulladulla and the Albury border before it disappeared from radar.
They cannot understand why authorities have not told the flying community about the dangers, particular as it will take at least another year before the bureau makes its final report.
Many within the aviation community believe the reason for the silence is concern that the tragedy will be blamed on the controversial air space category known as G-airspace, where authorities say it is too expensive to control air travel.
"The public needs some action now, not in 12 months' time when they finish their report," Mr Henderson said yesterday.
"I'm not after blaming someone, but I am concerned that air traffic procedures do not appear to be as robust as we are told. Why else would a highly qualified, professional pilot flying a well-maintained and equipped plane have this type of accident.
"I have asked both the ATSB and Civil Aviation Safety Authority to put out some statement, some warning, but it all seems too hard.
"If there is another accident in the meantime, then I believe they should be held accountable."
Barry and Lex Stark, parents of Alan, who was a Black Hawk helicopter pilot, have been even more frustrated since the accident; ignored by aviation authorities who have not even telephoned their Queensland home to inform them of the impending report.
"I did not appreciate being left out of the loop, particularly when there are so many unanswered questions about why they were so far off track. It seems ridiculous that authorities are sitting there with millions of dollars of equipment, simply noting that an aircraft in bad weather is off track and doing nothing about it.
"People should be made aware of the problems."
Like the other family members, Geoff Brockie's aunt, Joy Fletcher, has visited the crash site and is shocked the pilot could have been so far off course. Mr Brockie had joined what was a joy flight for the afternoon and was due to pilot an international Qantas flight out of Melbourne the same night.
"We haven't been told anything beyond what has been said publicly, and that is not enough to answer our questions. It seems amazing that they could fly so far, through several control zones without a warning. It makes you wonder about other flights."
Airservices Australia remained silent yesterday. It is understood that initial internal inquiries told the board of three occasions before the plane flew into uncontrolled air space that the pilot could have been warned about his flight path.
Mr Henderson has met the Civil Aviation Safety Authority and asked for changes to air space management. But a spokesman for the authority said yesterday its hands were tied until the bureau finished its report.
The Minister for Transport, John Anderson, has announced that Airservices Australia will be stripped of its air space regulatory functions if the Government is re-elected. The power would be transferred to a separate body - the Airspace Directorate.
Source: http://www.smh.com.au/articles/2004/09/16/1095320900824.html
By Robert Wainwright
September 17, 2004
Two Melbourne air traffic controllers have been stood down after preliminary investigations into the death of six people aboard a plane which crashed on a flight from Bankstown to the Victorian town of Benalla two months ago.
The fallout from the tragedy is set to reignite a verbal war over aviation safety as the Federal Government prepares to overhaul the way air space is managed.
Inquiries by the Herald have revealed that Airservices Australia board members discussed the crash a month ago, including detail that the pilot, Kerry Endicott, was not warned on three occasions that he had drifted dangerously off course on the Ulladulla-Benalla leg of the journey.
By the time the plane reached the crash site an hour later, it was 12 kilometres south of the check- point Mr Endicott thought he was heading towards.
He had been flying in cloud cover and rain that made it impossible to realise his error. When he banked left to prepare to land, the Piper Cheyennecrashed into mountainous countryside, killing all on board instantly.
The families of the victims spoke yesterday for the first time since the July 28 tragedy. They are concerned about time it will take authorities to finish their investigations and potential safety problems for others in the meantime.
David Henderson is mourning his brother, businessman Robert Henderson, and niece, Jacqui Stark. They died along with Jacqui's husband, Alan, his friend Geoff Brockie, Belinda Andrews and Mr Endicott.
Mr Henderson said the preliminary report from the Australian Transport Safety Bureau made it clear the plane crashed because it was off course and that Mr Endicott, an experienced pilot, punched the wrong co-ordinates into GPS equipment.
However, they do not know why the plane was allowed to veer almost four degrees from its designated flight path, through controlled air space for hundreds of kilometres between Ulladulla and the Albury border before it disappeared from radar.
They cannot understand why authorities have not told the flying community about the dangers, particular as it will take at least another year before the bureau makes its final report.
Many within the aviation community believe the reason for the silence is concern that the tragedy will be blamed on the controversial air space category known as G-airspace, where authorities say it is too expensive to control air travel.
"The public needs some action now, not in 12 months' time when they finish their report," Mr Henderson said yesterday.
"I'm not after blaming someone, but I am concerned that air traffic procedures do not appear to be as robust as we are told. Why else would a highly qualified, professional pilot flying a well-maintained and equipped plane have this type of accident.
"I have asked both the ATSB and Civil Aviation Safety Authority to put out some statement, some warning, but it all seems too hard.
"If there is another accident in the meantime, then I believe they should be held accountable."
Barry and Lex Stark, parents of Alan, who was a Black Hawk helicopter pilot, have been even more frustrated since the accident; ignored by aviation authorities who have not even telephoned their Queensland home to inform them of the impending report.
"I did not appreciate being left out of the loop, particularly when there are so many unanswered questions about why they were so far off track. It seems ridiculous that authorities are sitting there with millions of dollars of equipment, simply noting that an aircraft in bad weather is off track and doing nothing about it.
"People should be made aware of the problems."
Like the other family members, Geoff Brockie's aunt, Joy Fletcher, has visited the crash site and is shocked the pilot could have been so far off course. Mr Brockie had joined what was a joy flight for the afternoon and was due to pilot an international Qantas flight out of Melbourne the same night.
"We haven't been told anything beyond what has been said publicly, and that is not enough to answer our questions. It seems amazing that they could fly so far, through several control zones without a warning. It makes you wonder about other flights."
Airservices Australia remained silent yesterday. It is understood that initial internal inquiries told the board of three occasions before the plane flew into uncontrolled air space that the pilot could have been warned about his flight path.
Mr Henderson has met the Civil Aviation Safety Authority and asked for changes to air space management. But a spokesman for the authority said yesterday its hands were tied until the bureau finished its report.
The Minister for Transport, John Anderson, has announced that Airservices Australia will be stripped of its air space regulatory functions if the Government is re-elected. The power would be transferred to a separate body - the Airspace Directorate.
Source: http://www.smh.com.au/articles/2004/09/16/1095320900824.html
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x marks the spot
I would have thought the GPS will give accurate information based on input co ordinates as its data source regardless of what method the a/c was being controlled by. You might like to elaborate smh 
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muddergoose.
A lot depends on what type of GPS was been used.
If it had a moving-map display, then yes, it is easy to see when one is off track.
If it wasn't a certified-for-IFR-use unit with a current database, then it's upto the user to insert the required waypoints, which raises the problem of accuracy.
GPS can only give an estimated position (due to timing errors, ionospheric propagation delays, multipath reflections, constellation geometry, spoofing, ...), but most of the time it's acceptable for aviation.
The data-processor in the GPS has to massage and filter that stream of position fixes into usefull information such as ground-speed, track, and you are here on this GPS approach.
A lot depends on what type of GPS was been used.
If it had a moving-map display, then yes, it is easy to see when one is off track.
If it wasn't a certified-for-IFR-use unit with a current database, then it's upto the user to insert the required waypoints, which raises the problem of accuracy.
GPS can only give an estimated position (due to timing errors, ionospheric propagation delays, multipath reflections, constellation geometry, spoofing, ...), but most of the time it's acceptable for aviation.
The data-processor in the GPS has to massage and filter that stream of position fixes into usefull information such as ground-speed, track, and you are here on this GPS approach.
I don't know how accurate GPS is in aircraft, but my old eight channel GPS and laptop moving chart software in my yacht give me an error of about twenty feet maximum - of course my maximum speed is about eight knots, not 180 kts!
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It would appear ATSB can cancel their investigation. Poison Dwarf not only knows the reason for this tragedy but bravely states that it wouldn't have happened if only the professionals in the industry had listened to the private pilots lobby group.
Your posts are usually so pathetic as to be unworthy of a response, Dwarf, but perhaps you would like to enlighten everybody as to how you have used your thorough investigation to suit your political ends.
Your posts are usually so pathetic as to be unworthy of a response, Dwarf, but perhaps you would like to enlighten everybody as to how you have used your thorough investigation to suit your political ends.
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Binoculars
When the truth stares at you in the face you can turn away but it will still be there when you turn back, wake up and stop living a dream. It does not take five seconds to reveal that this accident could have been prevented sham on you. I have no political ends just see **** from shineola do you get it? When is Aus going to wake we have the most bastardised airspace system in the world and we still think Aus is unique interesting to note we are the only country in the world arguing about airspace and have one of the worst records the rest of them are just getting on with it. You should start looking at the big picture.
PD
When the truth stares at you in the face you can turn away but it will still be there when you turn back, wake up and stop living a dream. It does not take five seconds to reveal that this accident could have been prevented sham on you. I have no political ends just see **** from shineola do you get it? When is Aus going to wake we have the most bastardised airspace system in the world and we still think Aus is unique interesting to note we are the only country in the world arguing about airspace and have one of the worst records the rest of them are just getting on with it. You should start looking at the big picture.
PD
Just to clarify the GPS bits...
For a GPS NPA you cannot enter your own waypoints. They are in the database card from Jeppesen etc. Reference AIP GEN something.
And to quote the ATSB report...
Yep...it was only a matter of time until this was politicised.
For a GPS NPA you cannot enter your own waypoints. They are in the database card from Jeppesen etc. Reference AIP GEN something.
And to quote the ATSB report...
The operation of the approved GPS carried for this flight, using the installed software, does not require manual input of waypoint position coordinates.
Yep...it was only a matter of time until this was politicised.
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You're on a tangent
Sounds to me like poison dwarf and binoculars have an axe to grind!
Focus your energy and create a successful outcome to anomolies within the system. If there is an issue with IFR GPS then lets make it public and resolve the issue. Ultimate outcome is to save lives. Unfortunately, too late for the six involved. If you have family, think about it!!!!!
My experince with IFR GPS is with Trimble TNL2000 and recently an Apollo GX-60. It offers parallel tracking and is approved for IFR, allbeit older than current models.
I read a report on PPRUNE the Pilot had 20,000 hours 1,500 on type and someone posted "Endicott checked him out in \'76 on particular type.
The Leg from Ulladulla to BLAED was approximately 230 nm according to a post. What was the pilot doing, having a snooze?
Compressor stall says you can\'t alter waypoints for IFR approach.
Ultimately. regardless of ATC, something has lead them astray. I\'m thinking the GPS.
If you can\'t place your faith in a GPS NPA approach, why use it at all?
We do believe GPS is the way but there are RF (Radio Frequency) issues or charge issues that could alter Binary storage, therefor these have to be addressed!
Focus your energy and create a successful outcome to anomolies within the system. If there is an issue with IFR GPS then lets make it public and resolve the issue. Ultimate outcome is to save lives. Unfortunately, too late for the six involved. If you have family, think about it!!!!!
My experince with IFR GPS is with Trimble TNL2000 and recently an Apollo GX-60. It offers parallel tracking and is approved for IFR, allbeit older than current models.
I read a report on PPRUNE the Pilot had 20,000 hours 1,500 on type and someone posted "Endicott checked him out in \'76 on particular type.
The Leg from Ulladulla to BLAED was approximately 230 nm according to a post. What was the pilot doing, having a snooze?
Compressor stall says you can\'t alter waypoints for IFR approach.
Ultimately. regardless of ATC, something has lead them astray. I\'m thinking the GPS.
If you can\'t place your faith in a GPS NPA approach, why use it at all?
We do believe GPS is the way but there are RF (Radio Frequency) issues or charge issues that could alter Binary storage, therefor these have to be addressed!
With respect, the only conclusion that can be drawn at this stage is that the pilot was not where he thought he was.
We don't know why. I'm sure the folk at ATSB will get to the bottom of it one way or another, probably re enacting the flight if necessary.
I have one question at the moment - the aircraft was apparently a constant 3.83 degrees off track. Is there another navaid or waypoint that the machinery could have been heading to instead of Benalla, such as Strathbogie?
We don't know why. I'm sure the folk at ATSB will get to the bottom of it one way or another, probably re enacting the flight if necessary.
I have one question at the moment - the aircraft was apparently a constant 3.83 degrees off track. Is there another navaid or waypoint that the machinery could have been heading to instead of Benalla, such as Strathbogie?
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Muddergoose,
After you ream others for their posts you then go on to criticise the pilot. Nice one.
And BTW 230nm in a high performance turbo prop is not far, a time interval of probably under an hour. Nothing for a professional pilot, and given the wheels and flaps were down I doubt he was asleep.
He did have lots of experience and had an experienced pilot next to him in the form of a QANTAS pilot with a military background. So I reckon, just a hunch, that there were eye's on what was happening and the fact it ended like this should be a reminder to all to be vigilant..
All you people here having a vent etc, shut your traps and go back to studying BAK.
We'll see what BASI have to say about this one.
After you ream others for their posts you then go on to criticise the pilot. Nice one.
And BTW 230nm in a high performance turbo prop is not far, a time interval of probably under an hour. Nothing for a professional pilot, and given the wheels and flaps were down I doubt he was asleep.
He did have lots of experience and had an experienced pilot next to him in the form of a QANTAS pilot with a military background. So I reckon, just a hunch, that there were eye's on what was happening and the fact it ended like this should be a reminder to all to be vigilant..
All you people here having a vent etc, shut your traps and go back to studying BAK.
We'll see what BASI have to say about this one.