ATSB failure in Benalla investigation

[Old Akro]

I fly on IFR plans on basically every flight, the vast majority of which is in class G airspace. And I pay the airservices charges. Part of the reason is that I'm under the belief that I'm paying someone to watch over me and that just maybe they'll catch a mistake that I make.

Without entering the debate of what equipment should or shouldn't be used and whether or not its good enough for radar to not go to the ground, the thing that disturbs me about this flight is that something did go wrong in the aeroplane. And a controller saw the error. And (from memory) the controller twice cancelled system warnings, but never made the radio call. Regardless of whether the blame lies with the Captain, or the GPS unit or Martians jamming the GPS signals, at Benalla on that day we had all the technology we needed. But it wasn't applied in a way that could have helped.

My reckoning is that the ASA charges for the hour or so of that flight was about $25. How much extra does it cost to get the radio call?

[james michael]

The question of 'extra cost' raises an interesting question re the NAS introduction.

22 Feb 2002 :
The Special Aviation Reform Group (ARG) consists of Dick Smith, the chairman of CASA, Ted Anson, and the chairman of Airservices Australia, John Forsyth.

"The group will consider two proposals for reforming Australia's low level airspace ‑‑ the Airspace Working Group's Low Level Airspace Reform Plan (LAMP), and the proposed National Airspace System (NAS).

AIRSPACE ADVISOR NO 1.1 OCT 2003, citing the ARG:
Airspace changes will be .... (16 pages follow)

LONGER TERM CHANGES (waiting still on much of this):

GAAPs redesignated as Class D

Enroute Directed Traffic Information (DTI) in Class G replaced with “flight following” traffic information service

Class E terminal airspace introduced at selected locations

several others

and
Key feature: IFR able to buy “add on” air traffic services in Class G.

Who is offering .... what .... and who is buying? Have we an expectation of ATC that has not yet been commercially followed through by the APG?

[peuce]

Dick & Co,

In a perfect world, it would be nice if ATC were able to monitor, police and shepherd us around the skies so that we never got ourselves into trouble.

The reality is that impracticalities often preclude it. For example:

• As was mentioned earlier, the scale of the radar screen required to service the Controller's area of responsibility can precludes monitoring small uncontrolled terminal areas
• After being "realeased" by ATC to make your arrival at an uncontrolled aerodrome, have you ever deviated from your planned track? Perhaps you've become visual, perhaps you abbreviated the approach, perhaps you've manouvered around another aircraft. Controllers see this all the time. Would you really want them to quizz every lighty who changed heading after descending OCTA?

You can't have your cake and eat it too.

It's either Controlled Airspace ( with staffing, resources and equipment issues); OR it's Uncontrolled Airspace and you become master of your own destiny ... including all the responsibilities that come with that.

I may be old fashioned Dick, but I really don't think there's a place for "grey" airspace

[overhere]

In a perfect wish list ATC would be able to do a lot of things...

1. Provide tracking as described during approaches in IMC (IFR in VMC should be able to keep themselves away from terrain),
2. Provide a level of traffic seperation in class G airspace bwteen VFR aircraft with Class C Transponders instead of waiting for near mid-airs to happen
3. Have radar coverage that they can use at GAAP/Class D airports instead of relying in pilots with questionable local area knowledge to advise of their locations that are often a number of miles out,
4. Seperation of IFR/IFR aircraft in Class G airspace,
5. Plus whatever else would keep me away from danger

As pilots however we have to be realistic and understand that firstly our companies and passengers don't have endless deep pockets to actually pay for this and secondly that we have to take some sort of responsability for ensuring we minimise the risks to our own flights.

Personally instead of a wish list I have just a few wishes that should be practical...

• Enough air traffic controllers to cover the sectors (no TIBA/TRA's)
• Enough Air Traffic Controllers that when I do have to fly VFR I can ammend a flight plan or SARTIME without being told to "stand-by" with no-one to ever get back to me - it's real useful to me if something goes wrong that a helicopter rescue team is looking for me in the other direction because I've changed my route for whatever reason - or Centre calling asking where I am when I've tried to ammend SARTIMEs on 3 different sectors only to be told to stand by each time - at least someone bothered looking I guess,
• Coverage at Class C/D/GAAP airports not just the minimum hours but during times whan aircraft movements are still predicted to be occuring - there's a number of incidents/accidents this would have prevented,
• Enough controllers that when a tower controller goes sick, we don't end up with CTMS delays that are an absolute joke.

Perhaps we could just try the basics first and then move on to the advanced - it isn't rocket science...

[Lookleft]

Dick- How come you are not mentioning the fitment of TAWS equipment to turbine aircraft of 6 seats or more? You did at the time of the original release of the Benalla accident and the ATSB issued a recommendation to CASA that this be done to bring Australia in line with the USA. No aircraft fitted with TAWS has been involved in a CFIT accident yet you are insisting that the answer to CFIT is in having more controllers.

[ferris]

Old Akro

I am going to have to speak up here. When you make alarming motherhood statements such as

Part of the reason is that I'm under the belief that I'm paying someone to watch over me and that just maybe they'll catch a mistake that I make.

makes me questions whether you understand enough to hold a pilots license. Do you understand the differing types of services offered, their responsibility and cost? When you are receiving a CONTROL SERVICE, you do indeed receive this level of 'oversight'. IFR services in G (ICAO F) were specifically designed so that you did not receive this level of service, in order to make the level of service you do receive, affordable. Heard that mentioned? And who drives this sort of thinking- because back in the days when AsA wasn't a business/tax collection arm, pilots received lots of services they didn't pay for. 'Noble crusaders' put an end to that. Your statement is akin to saying you look at MOST traffic lights when driving, but hope the police will step in if you miss one. It would probably work if we could afford to have a policeman at every traffic light, but ring Dick and ask him about affordable safety.

And (from memory) the controller twice cancelled system warnings, but never made the radio call.

The machine has to be seen to be believed. (also from memory) On the average shift, depending on where you sit, you will receive between 35 and 80 false alarms of one sort or another. It sounds negligent to read of alarms cancelled and not actioned- but it's not as simple as that. It's not a passive job- you dont sit there waiting for alarms before doing things. You ACTIVELY CONTROL the aircraft you ARE SUPPOSED to. You provide the level of service to the others that you are SUPPOSED TO. When an alarm goes off a thousand times or more before it is actually alerting you to something, it ceases to be an alarm/alert.

BTW- excellent point Lookleft.

[Dick Smith]

Lookleft, regarding the TAWS, yes it is a point I have consistently made. CASA has a policy that we should harmonise with leading aviation countries, yet they have not introduced this basic TAWS requirement.

I haven’t seen the ATSB recommendation to CASA regarding this. Can you direct me to where it may be? I have generally found that the ATSB does not make recommendations which offend the powerful – that is why they didn’t mention TAWS or using the radar more effectively in the original report on the Benalla accident.

I find it fascinating that posters are coming up with every reason why we can’t simply use the existing radar with the existing number of controllers to provide a safety back up to pilots when they make an error.

I can assure you that when an error is made by a jet airline pilot at Proserpine, and over 150 people are killed, the radar will be used after the Royal Commission. Why not use it now?

Most of the arguments I read here are all about resisting change. If air traffic controllers in the USA, the UK, and most other countries can issue a MSAW alert in all airspace, why can’t we do so in Australia?

[james michael]

Key feature: IFR able to buy “add on” air traffic services in Class G.

The above was released in the NAS document by the ARG.

Including radar advice? When will this NAS feature be enabled - or have I missed it - and is this not what is being suggested?

Enables the retention of the much espoused "Free in G" but PIC decision on services at a cost. No?

[para adams]

Duty of Care?

I also share Old Akro's concerns as to the inaction of ATC in the lead-up to the Benalla accident.

Let us assume that I am standing on the side of a swimming pool. I am dressed for swimming and I can swim. There is one other person already in the swimming pool and I see that he is drowning. Am I obliged to go to his assistance? If I do not the person will drown.

The Northern Territory has "Good Samaritan Laws" which require me to go to that person's assistance. The other jurisdictions in Australia have "Criminal Negligence" provisions which require me to assist if I owe that person a duty of care. Failure to provide assistance may lead to a charge of manslaughter.

Accordingly, did ATC owe the pilot and passengers of the Benalla flight a duty of care? Is it relevent that the flight was an IFR flight?

The law of "duty of care" was established in Donohue v Stephenson (1932) AC 562, the famous "snail in the bottle" case, wherein Lord Atkin said:-
"You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who then in law is my neighbour?
The answer seems to be - persons who are so clearly and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to acts or omissions."

I suggest that ATC did owe the pilot and passengers a duty of care. The pilot had registered the flight to make use of ATC's expertise and relied on it. It is also arguable that ATC owes a duty of care to all users of the skies, regardless as to whether the user is an IFR user or a VFR user.

For ATC to ignore the two warnings received and not to advise the pilot of these is a breach of the duty owed by ATC. This is an area which should be explored by the appropriate agencies, including the Coroner.

[peuce]

Dick,

You continually confuse principles with practicalities.

Yes, we all agree with you ... it would be nice and it would be a good thing!

Now that we have that out of the way ...

How do you propose that we implement it, taking into account current Australian Legislation, resources and funding?

P.S. Who pays for the ATC Services in the US & UK?

[peuce]

Para Adams,

There's some big words there and I'm in no position to comment on the Coroner's findings in the Benalla, or any other case ... because I don't have all the facts or expertise.

However, in general, say you were standing on the edge of that pool and there were 35 kids all yelling, screaming and waving their arms ... which would you consider was drowning, if any, and which would you save, if any?

And what if you stood on the side of that pool every day and saw the same kids yelling and screamimng and waving everyday ... how concerned would you be?

[OZBUSDRIVER]

Trust your POH! Do not be a test pilot! John is going to cop it next time I get checked out by my favourite ATO.

[para adams]

Peuce,
To use your analogy - you are the lifeguard.You are warned twice that the red headed boy (and there is only one red headed boy in the pool ) is in danger but because you frequently receive such a warning and the warnings are often false, you do nothing, notwithstanding that you see the red headed boy.
Haven't you failed in your duty to the red headed boy?
I suggest that ATC is the lifeguard and is not an uninterested bystander. As such it should acted on its duty of care and warned the pilot. If the warning was false than nothing has been lost.

[ForkTailedDrKiller]

I wonder if there were too many pilots aboard that aircraft?

Dr

[peuce]

I don't want to prolong this too much ... but my point was that ... the lifeguard has been hired to watch over the toddlers in the baby pool. He does so, diligently, but out of the corner of his eye, he is often distracted by the other kids in the big pool ... yelling, screaming and waving their hands.

I say he should confine his attention to the toddlers pool. If the council thinks the kids in the big pool need to be watched more closely ... then they need to hire a lifeguard to monitor them.


To change the subject completely ... I don't think we need to worry at all. The Government has got it all sussed ... albeit a few years ago and hopefully their position has changed slightly. But reading the article (Background Paper 10 1997-98) that James Michael linked to previously ...

"..So in the end, passengers must decide for themselves whether carrier service and safety levels are appropriate. Consumer advocates offer some suggestions to aircraft passengers such as wearing clothes made of natural fibres that are less prone to burning, and carrying a personal smoke hood with which to survive any emergency evacuation. Passengers should learn to report any unusual activities at the airport and ask questions during safety briefings. They should remain alert during takeoff and landings, but above all stay calm. In most cases, their flight is in the hands of many professional people with a fine record..."

[james michael]

Para

The red haired boy was not singled out for a warning - there were 100 red haired people in the pool, all crying out and no-one knew which one was drowning. That's about the statistic for valid RAM alerts I understand.

Answer, bring in another 10 lifeguards - who pays and really, why? From what Dick has posted re the Chew report it seems the duty of care was not predominantly with ATC.

Answer to duty of care - checked MATS and it did not come up in the search.

But, this is all water under the bridge as MATS has been amended to resolve ambiguity re alerts we are told.

[nick2007]

hopefully their position has changed slightly

I hope so too:

"..So in the end, passengers must decide for themselves whether carrier service and safety levels are appropriate...."

99% of passengers do not have the information necessary to make that judgement.

..."Consumer advocates offer some suggestions to aircraft passengers such as wearing clothes made of natural fibres that are less prone to burning, and carrying a personal smoke hood with which to survive any emergency evacuation. "

As for BYO emerg evacuation equipment... That could work quite well in the departure lounge.
"Smoke hoods! Smoke hoods! Get ya smoke hoods here! Don't board without 'em! 2 for $10!.... Oooo sir, those polyester pants will do wonders for your skin complexion in the PIF, but I have the solution for you right here... stylish hemp cords, only $15".

[james michael]

Nick

I'll take the cords - will you accept $13?

You raise a point of interest and it is

99% of passengers do not have the information necessary to make that judgement.

It is applicable to this flight. Certainly, 99% of fare paying pax - at times when there is no media beat up of RPT - make their judgement that they are getting on a big bus with wings and expert drivers, to get from A-B.

On a PVT flight in a rattly old clunker, the passengers are far more aware of the risk. This flight was not RPT.

It is well covered in the CASA document CEO-PN001-2004.

[ferris]

Most of the arguments I read here are all about resisting change.

Dick, this thread ties beautifully several strands that you have, up until now, argued independantly. Those who "resist", as you put it, are simply aware that what you want cant be done. It's a matter of funding/affordable safety/whatever you want to call it.
Everyone associated with the industry is aware that GA runs on a shoe string. It is not widely acknowledged that it is essential to the country. Whilst we continue down this user pays road that you advocate, we cannot supply GA with a Rolls Royce service on a shoe-string budget. Until YOU step up and acknowledge that the "US System" is indeed a "System", including the all-important funding model of the supporting infrastructure, this "resistance" you speak of will continue.

ATC. Flight Service. Met. Regulators/Overseers. Funding model/Charging regime. Infrastructure. Rule set.

Thats a "System".

[Air Ace]

"It is applicable to this flight. Certainly, 99% of fare paying pax - at times when there is no media beat up of RPT - make their judgement that they are getting on a big bus with wings and expert drivers, to get from A-B.

On a PVT flight in a rattly old clunker, the passengers are far more aware of the risk. This flight was not RPT.

It is well covered in the CASA document CEO-PN001-2004."

You are wrong - and I doubt even the remaining 1% of air travellers will ever read CASA document CEO-PN001-2004.

99% of the consideration of 99% of intending passengers on any form of air travel, is the price they pay.

Nothing absolves the regulator from it's duty of care mandated in Sect 9 of the Civil Aviation Act 1988 and certainly not a policy statement by CASA's CEO!