Lockhart River Coroners Findings (Merged)
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Lockhart River Coroners Findings (Merged)
Well having read the whole things there are some terms such as “Systemic Bias” which is tragic.
To me it seems that given all the pointers, going all the way back to ’99 and the gent that went to the ATSB who was referred to CASA, the holes in the swiss cheese had been forming for a long time.
As an outsider looking in, it appears that the event was only a matter of time.
What gives me insight, I was a Chief Pilot of a turbine operator in FNQ, and approved under CAR 217 just like these fellas but I have to say that the inspection of our operation by Tony M, Peter Mac & Bill Mc were a lot more rigorous.
Having operated over the same terrain I understand intimately the weather and the operational requirements. (Think trying to explain to an owner why going to HID I needed Weipa as an alternate - crews not yet endorsed for DGA), outside their cost model someone once said.
The final insult to me is that the plane cost half of what the investigation cost
The report indicates that the whole thing was completely avoidable. Tragic.
To me it seems that given all the pointers, going all the way back to ’99 and the gent that went to the ATSB who was referred to CASA, the holes in the swiss cheese had been forming for a long time.
As an outsider looking in, it appears that the event was only a matter of time.
What gives me insight, I was a Chief Pilot of a turbine operator in FNQ, and approved under CAR 217 just like these fellas but I have to say that the inspection of our operation by Tony M, Peter Mac & Bill Mc were a lot more rigorous.
Having operated over the same terrain I understand intimately the weather and the operational requirements. (Think trying to explain to an owner why going to HID I needed Weipa as an alternate - crews not yet endorsed for DGA), outside their cost model someone once said.
The final insult to me is that the plane cost half of what the investigation cost
The report indicates that the whole thing was completely avoidable. Tragic.
From memory, "Mr Ian Harvey" wrote the CASA report. 
Good to see that things are on a level playing field
Good to see that things are on a level playing field
Last edited by snoop doggy dog; 18th Aug 2007 at 00:38. Reason: Grammer
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Casa/atsb
Just read the Coroners report on the Lochart River accident and wonder what his comments have to say about the regulatory authorities. Are things really as bad as he hints, and more importantly what is/are the problem/s?
CASA had senior, expert legal representation who I’m sure would not have made such a sustained attack on the integrity of the ATSB investigation report without explicit instructions. In my view, these protestations are symptomatic of serious, ongoing animosity between the two organisations that needs redressing. I shall return to the issue in the recommendation section of these findings.
Interaction between the ATSB and CASA
Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.
Seems to be a total disconnect with CASA's view of aviation safety and reality when the they put forth "CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash." The sort of statement you would expect to see written by a know nothing tabloid journalist, not a body entrusted with the regulation and safety of the industry. I'm sure they have even met James Reason, or is that an unreasonable assumption?
CASA had senior, expert legal representation who I’m sure would not have made such a sustained attack on the integrity of the ATSB investigation report without explicit instructions. In my view, these protestations are symptomatic of serious, ongoing animosity between the two organisations that needs redressing. I shall return to the issue in the recommendation section of these findings.
Interaction between the ATSB and CASA
Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.
Seems to be a total disconnect with CASA's view of aviation safety and reality when the they put forth "CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash." The sort of statement you would expect to see written by a know nothing tabloid journalist, not a body entrusted with the regulation and safety of the industry. I'm sure they have even met James Reason, or is that an unreasonable assumption?
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Well Hello...??? Lockhart, Anybody??
I'm really surprised that no-one has reacted to the coroner's findings on Lockhart.
Putting aside the expected 'prime suspects', why wasn't CASA singled out for specific condemnation - and legal action......
Putting aside the expected 'prime suspects', why wasn't CASA singled out for specific condemnation - and legal action......
Fascinating
Interesting that this thread has been moved to D&G General Aviation & Questions the place for students, instructors and charter guys rather than being left on D & G Reporting Points Airline and RPT issues in Australia and enZed. I thought this Aerotropics flight operated by Transair was RPT.
Interesting that people promote Reason and come up with one major cause for the accident. No aviation safety regulator has the hand of God to stop accidents. Look at the road kills around Australia.
Interesting that no one is considering the responsibilities of the operator. He owned and operated the company. The containment of risk was his primary responsibility.
Interesting that no one is being reflective on the pilot in command responsibilities.
Interesting that none of the 'informed' members of the industry had the gumption to put their concerns formally before the accident.
Interesting that the ATSB report in relation to the pilots actions was discredited by the Coroner. Where is the professional analysis of the report in the context of the Coroner's findings.
Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.
Interesting that people promote Reason and come up with one major cause for the accident. No aviation safety regulator has the hand of God to stop accidents. Look at the road kills around Australia.
Interesting that no one is considering the responsibilities of the operator. He owned and operated the company. The containment of risk was his primary responsibility.
Interesting that no one is being reflective on the pilot in command responsibilities.
Interesting that none of the 'informed' members of the industry had the gumption to put their concerns formally before the accident.
Interesting that the ATSB report in relation to the pilots actions was discredited by the Coroner. Where is the professional analysis of the report in the context of the Coroner's findings.
Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.
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Frank Burden - I have to whole heartedly agree with you
Maybe because of post #9 
Page 53 of the Coroners report (bolding mine)
Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.
Page 53 of the Coroners report (bolding mine)
Primary responsibly for the incident must rest with the captain of the aircraft, a highly experienced and competent pilot. He knew that the approach he was planning to undertake into Lockhart River on 7 May was inconsistent with official regulations and Transair’s policies. He must have also known that his departure from it was fraught with risk. The contribution of the co-pilot, if any, can not be known. CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash. I don’t accept that. There is no evidence that Captain Hotchin was suicidal or that he habitually disregarded his safety of that of his passengers. It is necessary therefore to consider the context in which the actions occurred and the external influences that may have impacted on his behaviour. That is what the ATSB report and these findings have attempted to do.
I have also found that Transair failed to adequately monitor its pilots and to take steps to ensure that they were all complying with its policies. In my view the evidence establishes that its safety management system (My comment - that includes CASA) and the performance of key personnel was sub-optimal.
I have highlighted what I consider to be a number of deficiencies in CASA’s surveillance and audit of Transair and its departure from its own procedures. I have made recommendations about how some of those issues could be addressed, as has the ATSB.
That does not mean that CASA is to blame for the crash. There is no compelling evidence that if it had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced.
I have also found that Transair failed to adequately monitor its pilots and to take steps to ensure that they were all complying with its policies. In my view the evidence establishes that its safety management system (My comment - that includes CASA) and the performance of key personnel was sub-optimal.
I have highlighted what I consider to be a number of deficiencies in CASA’s surveillance and audit of Transair and its departure from its own procedures. I have made recommendations about how some of those issues could be addressed, as has the ATSB.
That does not mean that CASA is to blame for the crash. There is no compelling evidence that if it had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced.
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Having read parts of the Coroner's Report I feel that some of his conculsions are based on legalities rather than practicalities.
For example he appears to dismiss the First Officer's ability to influence the approach as he was not qualified to conduct a GPS NPA. I don't find this credible. I am not qualified to do a GPS approach but I can sure read and interpret the approach plate as I am sure most IFR qualified pilots can do.
The Coroner also seems to be saying that the Captain was attempting to get visual based on comments made to an inquest concerning a previous fatal crash. This is despite the fact that the Lockart River R12 approach is over high ground. If the approach had been made from the opposite direction then the comment may have had more validity.
The prospect of a lack of situational awareness is given scant attention.
However, the Coroner's conclusions, quoted by Brian Abraham, would appear correct. The handling pilot's performance in the past and apparently on the day was less than professional. It was a crash waiting to happen. The CASA oversight program is a joke. It gives lip service to compliance of the regulations by only doing paper audits. They serve to absolve CASA of any responsibility for when things go pear shaped, they most certainly do not detect actual non-compliance. The company is now no longer but it also appears to have been less than satisfactory in its running of its operations. The chickens appear to have come home to roost.
Will aviation learn from this crash. Probably not. It most certainly learnt nothing from Seaview, Monarch and Whyalla. Why should this one be any different? Let's just blame someone else.
For example he appears to dismiss the First Officer's ability to influence the approach as he was not qualified to conduct a GPS NPA. I don't find this credible. I am not qualified to do a GPS approach but I can sure read and interpret the approach plate as I am sure most IFR qualified pilots can do.
The Coroner also seems to be saying that the Captain was attempting to get visual based on comments made to an inquest concerning a previous fatal crash. This is despite the fact that the Lockart River R12 approach is over high ground. If the approach had been made from the opposite direction then the comment may have had more validity.
The prospect of a lack of situational awareness is given scant attention.
However, the Coroner's conclusions, quoted by Brian Abraham, would appear correct. The handling pilot's performance in the past and apparently on the day was less than professional. It was a crash waiting to happen. The CASA oversight program is a joke. It gives lip service to compliance of the regulations by only doing paper audits. They serve to absolve CASA of any responsibility for when things go pear shaped, they most certainly do not detect actual non-compliance. The company is now no longer but it also appears to have been less than satisfactory in its running of its operations. The chickens appear to have come home to roost.
Will aviation learn from this crash. Probably not. It most certainly learnt nothing from Seaview, Monarch and Whyalla. Why should this one be any different? Let's just blame someone else.
A simple question for the more knowledgeable and experienced here....
I note previous threads, some years old, about the standards and behaviours of certain North Queensland CASA staff (only known by their nicknames, such as "Pinocchio"), all of whom have apparently now departed in the face of the "New Broom" - BB.
May I ask if certain of these gentlemen were responsible for auditing Transair?
I note previous threads, some years old, about the standards and behaviours of certain North Queensland CASA staff (only known by their nicknames, such as "Pinocchio"), all of whom have apparently now departed in the face of the "New Broom" - BB.
May I ask if certain of these gentlemen were responsible for auditing Transair?
OK I'm going to get absolutely burned alive here however, was I the only person that was surprised by the shear volume of spelling, grammatical and formatting errors in what is supposed to be a rather important and official report? Sorry for the drift and just delete this if its too out of line.
Good Question Fishy,
As an RPT operator in FNQ we were supervised by the Brisbane “RPT/High Capacity” FOI’s not by TSV staff.
We were however ramp checked by TSV staff who demonstrated their complete lack of knowledge of turbine aircraft on more than one occasion. 
Licences, Medicals, Loadsheets, manuals…… no problem
. Turbine aircraft and higher caliber systems….. forget it
I would be very surprised if they (TSV) had inspection accreditation of the Transair group.
As an RPT operator in FNQ we were supervised by the Brisbane “RPT/High Capacity” FOI’s not by TSV staff.
We were however ramp checked by TSV staff who demonstrated their complete lack of knowledge of turbine aircraft on more than one occasion.
Licences, Medicals, Loadsheets, manuals…… no problem
. Turbine aircraft and higher caliber systems….. forget itI would be very surprised if they (TSV) had inspection accreditation of the Transair group.
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Page 37 of the Coroners Report States that the pilots had not been "Cleared to Line".Please Excuse me if Im abit naive but I've never worked for a company in charter or RPT (and thats been a few)that have not conducted a rigorous check to line with plenty of paper work filled out at the end of it.
If this is the case then certain people with in the company and CASA do have a very serious case to answer.
Regards The Dog
If this is the case then certain people with in the company and CASA do have a very serious case to answer.
Regards The Dog
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To the contrary Mr Burden, I find nothing trivial about Australia’s worst scheduled air service accident in 30 years.
The thread was started in this forum and a parallel thread started later in Reporting Points, was merged with this thread. I’m happy to move the thread to Reporting Points if you think it will make one iota difference to the lessons we should learn from this tragic event?
I too read the Coroner’s Report and am mystified that certain important regulatory and operational issues upon which one would expect the Coroner to investigate or at least comment, fail to rate a mention in the Report.
Seven people perished in the June 1993 Monarch Airlines Piper Chieftain crash at Young, NSW, nine people perished in the October 1994 Seaview Commander 690B disappearance enroute to Lord Howe and eight people perished in the May 2000 Whyalla Airlines Piper Chieftain disappearance into Spencer Gulf, all three accidents being extensively investigated (including numerous and extensive formal inquiries) and important lessons were learned.
And yet fifteen people tragically and needlessly died at Lockhart River in the worst air disaster in thirty years and we are to learn nothing except the cause was “pilot error” and CASA and the ATSB don’t always cooperate?
No Mr Burden, the Lockhart River accident was not trivial. I’m not sure I could make the same comment regarding the Coroner’s findings. Indeed, one could be excused for feeling the legal profession and perhaps even certain politicians got the report they sought.
The thread was started in this forum and a parallel thread started later in Reporting Points, was merged with this thread. I’m happy to move the thread to Reporting Points if you think it will make one iota difference to the lessons we should learn from this tragic event?
I too read the Coroner’s Report and am mystified that certain important regulatory and operational issues upon which one would expect the Coroner to investigate or at least comment, fail to rate a mention in the Report.
Seven people perished in the June 1993 Monarch Airlines Piper Chieftain crash at Young, NSW, nine people perished in the October 1994 Seaview Commander 690B disappearance enroute to Lord Howe and eight people perished in the May 2000 Whyalla Airlines Piper Chieftain disappearance into Spencer Gulf, all three accidents being extensively investigated (including numerous and extensive formal inquiries) and important lessons were learned.
And yet fifteen people tragically and needlessly died at Lockhart River in the worst air disaster in thirty years and we are to learn nothing except the cause was “pilot error” and CASA and the ATSB don’t always cooperate?
No Mr Burden, the Lockhart River accident was not trivial. I’m not sure I could make the same comment regarding the Coroner’s findings. Indeed, one could be excused for feeling the legal profession and perhaps even certain politicians got the report they sought.
I can assure you that CASA's TL office have recently taken some huge strides towards cleaning up the cowboy GA operators in NQ - NOT.
Dr
Dr
Last edited by ForkTailedDrKiller; 19th Aug 2007 at 10:18.
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FTDK. Are you referring to those employed within the CASA FNQ offices, or FNQ GA operators in general?
Aside from the odd immovable geriatric, I agree almost all CASA FNQ staff have changed in the past few years.
Surveillance of the AOC holder involved in the Lockhart River accident emanated from the CASA Airline Office in Brisbane - not the CASA offices at TL or CS.
Aside from the odd immovable geriatric, I agree almost all CASA FNQ staff have changed in the past few years.
Surveillance of the AOC holder involved in the Lockhart River accident emanated from the CASA Airline Office in Brisbane - not the CASA offices at TL or CS.
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Sadness
A chain of events which ended with the deaths of innocent parties. There is a lot in this. I won't point a finger at anyone specific, rather a group of people, organisations, regulators and individuals who should have known better! If each party allows irregularities to go uncorrected then disaster is the ultimate outcome. It could have all been avoided.