ATSB failure in Benalla investigation
Thread Starter
ATSB failure in Benalla investigation
Many will remember that after nearly 18 months of investigation, the ATSB came out with its report on the Benalla fatal accident with a press release which said, “Unfortunately, despite these prolonged efforts, the reason for the tracking error could not be determined.”
What a joke. Evidence has been provided to the Coronial Inquest in Victoria that if the aerial is simply disconnected or has a fault, the Trimble GPS will fly the exact route of the accident aircraft. How could the ATSB get it so wrong?
More to the point, how could they write a final report after such and extensive time and not mention the “elephant in the room.” That is, the lack of the use of radar in uncontrolled airspace in Australia to prevent Controlled Flight Into Terrain accidents.
It is interesting that the Counsel assisting the Coroner, Mr John Langmead (a pilot who had told me that he had done previous work representing the ATSB), did everything he could to protect the ATSB from any investigation. Here is a quote from his opening address.
Obviously not the “experts” who wrote the ATSB report which completely missed the most fundamental issue of all. That is, as stated above, the Trimble unit is so flawed in its design it can go into Dead Reckoning and completely replicate an instrument approach many miles away from where it actually is.
There are others at the Inquest who are going to make sure that any matters in relation to the air traffic service – i.e. the airspace and the use of radar – are not really looked into. Note the following quote from Ian Harvey, the learned counsel representing Airservices Australia at the inquest.
Of course, Mr Harvey’s proposal completely ignores the fact that the ATSB report is totally wrong, and therefore would certainly require some “adumbration” (whatever that means) or “elaboration”. The Airservices internal report would no doubt have not addressed in any way the lack of Minimum Safe Altitude Warning (MSAW) system in radar covered uncontrolled airspace in Australia.
The counsel for the family, Mr Jay Anderson, proposed that I be called to give some of the evidence that others so much wanted suppressed. Interestingly, the counsel assisting the Coroner, John Langmead, was violently opposed to me appearing. In a 10 minute “rant” to the Coroner, he came up with every possible legal technicality as to the reason I should not be allowed to appear.
The Coroner took Mr Langmead’s advice, and a copy of the Coroner’s decision is on my website here, together with my statement that was prepared and paid for by the Henderson family.
I think the whole issue is very sad for the families concerned, and it is telling that the ATSB has not issued an immediate and urgent warning to all pilots on how their report was completely wrong, and that pilots should be aware that the Trimble unit may go into Dead Reckoning mode – and without manual inputs can fly a complete approach in a different location. I hereby warn pilots of this issue. My suggestion is to throw out your Trimble units and get a decent Garmin today.
What a joke. Evidence has been provided to the Coronial Inquest in Victoria that if the aerial is simply disconnected or has a fault, the Trimble GPS will fly the exact route of the accident aircraft. How could the ATSB get it so wrong?
More to the point, how could they write a final report after such and extensive time and not mention the “elephant in the room.” That is, the lack of the use of radar in uncontrolled airspace in Australia to prevent Controlled Flight Into Terrain accidents.
It is interesting that the Counsel assisting the Coroner, Mr John Langmead (a pilot who had told me that he had done previous work representing the ATSB), did everything he could to protect the ATSB from any investigation. Here is a quote from his opening address.
…the ATSB is a repository of great expertise and it is that expertise that this inquest will have the benefit of and in my respectful submission this inquest ought not be permitted to become an investigation to vindicate or attack their investigative methods or the content of their report.
It is not their report that is significant, it is their evidence as experts…
It is not their report that is significant, it is their evidence as experts…
There are others at the Inquest who are going to make sure that any matters in relation to the air traffic service – i.e. the airspace and the use of radar – are not really looked into. Note the following quote from Ian Harvey, the learned counsel representing Airservices Australia at the inquest.
Your Honour may reasonably take the view that between the ATSB report and Airservices' internal report, there are few if any matters concerning Air Traffic Services issues that really require much further adumbration or elaboration.
I was interested in Mr Langmead's comment that a primary focus of the inquest should be in respect of other issues
I was interested in Mr Langmead's comment that a primary focus of the inquest should be in respect of other issues
The counsel for the family, Mr Jay Anderson, proposed that I be called to give some of the evidence that others so much wanted suppressed. Interestingly, the counsel assisting the Coroner, John Langmead, was violently opposed to me appearing. In a 10 minute “rant” to the Coroner, he came up with every possible legal technicality as to the reason I should not be allowed to appear.
The Coroner took Mr Langmead’s advice, and a copy of the Coroner’s decision is on my website here, together with my statement that was prepared and paid for by the Henderson family.
I think the whole issue is very sad for the families concerned, and it is telling that the ATSB has not issued an immediate and urgent warning to all pilots on how their report was completely wrong, and that pilots should be aware that the Trimble unit may go into Dead Reckoning mode – and without manual inputs can fly a complete approach in a different location. I hereby warn pilots of this issue. My suggestion is to throw out your Trimble units and get a decent Garmin today.
Last edited by Dick Smith; 13th Aug 2008 at 00:54.
Thread Starter
Yes, but that would not have helped if the aircraft was on track but descended too early - the most common form of CFIT accident.
Why not use radar when it is available?
Why not use radar when it is available?
Last edited by Dick Smith; 14th Aug 2008 at 23:35.
Perhaps, if the Trimble has such a fundamental flaw, it is CASA or the manufacturer that should be queried. Didn't they approve it for use? Surely the manufacturer knows about this defect?
Jeppesen has recently announced they will not be providing database updates for some Trimble models after Mar 2009.
AOPA Online: Jeppesen to end updates for older IFR GPS receivers
AsA cannot man the current airspace, let alone class E to 700ft everywhere.
Jeppesen has recently announced they will not be providing database updates for some Trimble models after Mar 2009.
AOPA Online: Jeppesen to end updates for older IFR GPS receivers
AsA cannot man the current airspace, let alone class E to 700ft everywhere.
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Dick, my understanding of the ATSB role is that they determine what happened from the facts they are presented with. They could not determine that the aerial had become disconnected or was faulty. That would be supposition.
Nor is it their role to decide what should have happened. Yes, they can make recommendations to prevent future crashes but only based on certain facts which in this case, were not certain.
I can understand your frustration with the present system but to criticise the ATSB for not presenting a report that would be based on probability is not going to help.
Nor is it their role to decide what should have happened. Yes, they can make recommendations to prevent future crashes but only based on certain facts which in this case, were not certain.
I can understand your frustration with the present system but to criticise the ATSB for not presenting a report that would be based on probability is not going to help.
Thread Starter
I have just heard from a retired US air safety expert and air traffic controller. He said in a situation such as Benalla, and
I wonder why the ATSB didn’t recommend that Airservices look at such a proposal here? Yes, I’ve heard all the claims about cost etc, but surely to do it at one airport (say, Proserpine, with large jet movements) the cost would not be prohibitive and the safety improvement would be important.
the aircraft goes below the MDA, the automation will initiate a Low Altitude Alert. At this point the controller is required to issue the alert and restate the MDA - in the case of a non precision approach - for example, a GPS approach.
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The nice thing about coronial inquests (I've been an expert witness at several) is that they usually look at aviation accidents with a different mind and different opinions to those of us who are involved in aviation in our daily lives.
There seems to be a view on these pages that the ATSB is beyond reproach. I agree that our ATSB investigators are some of the best in the world, but they can, and do get it wrong from time to time. It is important therefore, that the ATSB, and in this case Airservices and CASA, are subjected to external scrutiny because this is how we can learn and develop even safer systems.
I am surprised at the extent to which some parties are going to try to limit the evidence presented to the coroner. Wouldn't it be better if all the potential contributors and mitigators where considered?
There seems to be a view on these pages that the ATSB is beyond reproach. I agree that our ATSB investigators are some of the best in the world, but they can, and do get it wrong from time to time. It is important therefore, that the ATSB, and in this case Airservices and CASA, are subjected to external scrutiny because this is how we can learn and develop even safer systems.
I am surprised at the extent to which some parties are going to try to limit the evidence presented to the coroner. Wouldn't it be better if all the potential contributors and mitigators where considered?
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After the Toowoomba C90 and Lockhart Metro Coronial findings, for justice to be done - and seen to be done - one would have thought it appropriate for the Coroner to avail himself of all possible evidence and submissions, from all parties.
After all, the Coroner has the discretionary power to accept, ignore or reject any evidence he believes irrelevent or incorrect.
When certain names consistently appear in every Coroners Inquest in respect to aviation matters, one can't help but feel the possibility of manipulation could occur.
After all, the Coroner has the discretionary power to accept, ignore or reject any evidence he believes irrelevent or incorrect.
When certain names consistently appear in every Coroners Inquest in respect to aviation matters, one can't help but feel the possibility of manipulation could occur.
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I'm not a man of huge means, however I would consider contributing funds to some kind of legal challenge if that is at all possible.
The Coroner has however made it clear that your testimony does not fit with the initial purposes of a Coronial inquest, however it should be included in testimony in order for the coroner to make recommendations for the future so this doesn't happen again - without your testimony, this can't happen.
As a minimum Dick if you haven't already, you should be taking this directly to the media with a statement near identical to what you have posted here. If the public knew that this was a known Trimble 'condition,' then the fact that this was known should not be ignored. If you believe that you can directly blame the deaths of 6 people on equipment that is fitted to other aircraft that could do the same thing, then people will surely listen and the media should definitely work with it. Go for it! It might take the heat off Qantas and put some on CASA and the ATSB for change!
The Coroner has however made it clear that your testimony does not fit with the initial purposes of a Coronial inquest, however it should be included in testimony in order for the coroner to make recommendations for the future so this doesn't happen again - without your testimony, this can't happen.
As a minimum Dick if you haven't already, you should be taking this directly to the media with a statement near identical to what you have posted here. If the public knew that this was a known Trimble 'condition,' then the fact that this was known should not be ignored. If you believe that you can directly blame the deaths of 6 people on equipment that is fitted to other aircraft that could do the same thing, then people will surely listen and the media should definitely work with it. Go for it! It might take the heat off Qantas and put some on CASA and the ATSB for change!
For DR? needs a GS and Start Position to be entered manually. Who in their right mind would trust a device AFTER entering that information? DR is a DEMO mode in the Trimble.
Better yet, how much information is available to a pilot off an expired datacard? What functions are locked in a Trimble with an expired Datacard? Can a pilot activate APR with an expired Datacard?
Better yet, how much information is available to a pilot off an expired datacard? What functions are locked in a Trimble with an expired Datacard? Can a pilot activate APR with an expired Datacard?
Thread Starter
OZ, You are totally wrong! The Trimble manual may say that it needs to have manual entry but in practice the unit will keep "flying" the last track and groundspeed.
Wait another couple of years and CASA is sure to advise pilots of this!
Wait another couple of years and CASA is sure to advise pilots of this!
In a shocking case of irony, the aircraft was one week away from a major avionics upgrade
A $1600 Garmin 296 GPSMap with the terrain warning activated may well have prevented both the Lockhart R and the Benalla crashes!
Kinda makes you think doesn't it!
Dr
If the Trimble really has such a major flaw/defect, would the FAA be sitting on their hands?
Would it really be left to the A - Australian - TSB or CASA to tell the world?
Would it really be left to the A - Australian - TSB or CASA to tell the world?
Thread Starter
OZEBUSDRIVER, You are amazing, do you work for the ATSB?
I can assure you the documents are wrong and thats why the ATSB got it wrong - they believed the documents without the simplest checking.
CaptainMidnight-Yes!
I can assure you the documents are wrong and thats why the ATSB got it wrong - they believed the documents without the simplest checking.
CaptainMidnight-Yes!
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Dick
Maybe you are corret, however assuming that the GPS was fine, can APPROACH MODE actually be selected with an out of date data card??
This is a question not answered.
If not, perhaps a pilot entered approach was being used and it was wrong. Finger trouble is not new.
J
Maybe you are corret, however assuming that the GPS was fine, can APPROACH MODE actually be selected with an out of date data card??
This is a question not answered.
If not, perhaps a pilot entered approach was being used and it was wrong. Finger trouble is not new.
J
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Fair enough..... but OZBUS seems to have info that the Trimble will not.
An IFR GPS that does not play by its manual is a bit strange, so what does it actually do?
Seems nothing much said in the ATSB report this yet Dick is convinced it does not work as advertised. Something fishy here!
J
An IFR GPS that does not play by its manual is a bit strange, so what does it actually do?
Seems nothing much said in the ATSB report this yet Dick is convinced it does not work as advertised. Something fishy here!
J
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I had the distinct pleasure of knowing 'K' the PIC on that faitful day thru a few years of flying in & out of BLA and simply chatting to him over a cuppa in town whilst he waited as we all did on charters back then. I have flown into BLA numerous times visually & via the NPA in PA42's & B200's & I'm 100% sure that there had to be a unique error in the Trimble GPS unit (aerial or no aerial problem) that wasn't picked up or noticed by 'K' during that particluar approach. The only thing that may have distracted 'K' on the day was his pax on board, a couple of them would have been very keen to observe the goings on especially during the approach. I'd like to think that it was an insidious error that probably none of us pilots would have picked up that ended "K's life & the unfortunate pax on that day. Trimble or no Trimble I rely on any GPS with the absolute minimum of trust. If it's a stand alone approach as in no other ground based aid at the airfield (as is the case at BLA) I add a bit for 'mum & the kids' whilst outside the circling area, sure that's strictly not correct but that's just me. Most GPS's of these types (Trimbles & KLN's etc) have poor situational awareness as in small screens in monochrome colour, this just adds to the workload single pilot.
We can argue this sad story 'till the cows come home, we lost a true airman that day, none finer!
CW
We can argue this sad story 'till the cows come home, we lost a true airman that day, none finer!
CW
Last edited by Capt Wally; 13th Aug 2008 at 12:38. Reason: better fix spelling or the spelling police will be on to me