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VH-PGW PA-31P-350 15 June 2010 Crash Investigation

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VH-PGW PA-31P-350 15 June 2010 Crash Investigation

Old 15th Jul 2010, 01:05
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VH-PGW PA-31P-350 15 June 2010 Crash Investigation

http://www.atsb.gov.au/media/1576030...043_prelim.pdf

The Australian Transport Safety Bureau (ATSB) today released the preliminary factual report into the 15 June 2010 aircraft accident that killed a pilot and a flight nurse in Canley Vale, NSW.The report presents the facts of the accident gathered by the ATSB's initial investigation.
The investigation is continuing.

The ATSB will examine the recovered aircraft components, maintenance records and operational issues. Investigators will also review the operator's flight crew training records and conduct further analysis on the air traffic control radar and voice recordings.

A final report is expected to be released within 12 months of the accident.

The preliminary report tells nothing new. However it's a fair call to say that if the pilot had elected to land at Richmond they may not have reached the crash site.

I guess back to the old adage "Get the plane on the ground ASAP"
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Old 15th Jul 2010, 01:19
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I really hope that the ATSB is able to find the mechanical problems with this aircraft.

From the data shown the pilot had this aircraft in an approx. 1,000'/min descent which would seem to indicate that he was trying to get back on the ground in a hurry. If correct, it again raises the question of "why not Richmond?"
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Old 15th Jul 2010, 01:41
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PLovett & 1a sound asleep

Why not Richmond? Maybe because it was considered unsuitable by the PIC.

From the preliminary report:

An AWS was also located at Richmond Aerodrome and the METAR issued at 0800 indicated that the wind was calm, the OAT 4º C, the dewpoint was 4º C, the visibility was 200 m with vertical visibility information being unavailable, and the QNH was 1033 hPa. An air traffic controller who was on duty in Richmond control tower later stated that the weather conditions at the aerodrome when the aircraft was flying over the Richmond area included a clear sky with a shallow fog that reduced visibility at ground level to 300 m.
YSRI RWY 28 ILS
Performance Cat A&B
DA = 360ft + PEC 50ft = 410ft, Vis = 1.2 km (forcast QNH)
DA = 307ft + PEC 50ft = 357ft, Vis = 0.8 km (actual QNH)

Last edited by 404 Titan; 15th Jul 2010 at 01:53.
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Old 15th Jul 2010, 02:39
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All depends what "shallow fog" means in this context. The correct definition is " low-lying fog that does not obstruct horizontal visibility at a level 2 m (6 ft) or more above the surface of the earth." In other words it is less than 2m deep, possibly less than 1m deep. Hardly a good reason to pass the runway by, particularly as the runway would have been clearly visible from altitude through such a thin layer.

The fact that vertical visibility info was unavailable tells you that the fog layer was not deep enough to cover the sensor.
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Old 15th Jul 2010, 02:57
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My feeling is the report may suggest that the pilot felt the need/duty/desire to return to Bankstown. Whether this is a real or perceived commercial pressure is another issue. In the real world nobody wants a bent a/c in their log book - whether it was your fault or not. Maybe that's something in aviation culture that needs changing. Certainly there are airlines that will not employ a pilot with any accident history, irrespective of the cause/outcome

The old saying "the second engine in a piston will only carry you to the crash site" somehow seems to fade after a few thousand twin hours.

In some ways it's not fair to critic what happened. BUT, I know everybody learns from investigations and I do hope there's a lesson in this at the end of the day
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Old 15th Jul 2010, 03:33
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remoak

The problem is that the horizontal visibility was 300 metres at ground level up to 2 metres and 800 metres visibility is required from the Cat 1 DA of 357 ft with an actual QNH all the way down to the runway. Having experienced this type of fog in Anchorage a number of times and conducting auto lands off all of them, I wouldn’t recommend trying to manually land in these types of conditions unless your ass was on fire because of the insidious way the lack of horizontal visibility creeps up on you at the last minute. Unfortunately from what I gathered from the preliminary report I doubt the PIC realised his ass was on fire until it was far too late.
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Old 15th Jul 2010, 03:38
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He should have declared atleast a pan call and stated he is drifting down on 1 engine at vyse, rather than descending rapidly to low altitudes to conform with ATC and being overconfident that his machine will have the desired performance when reaching his descent altitude.

Last edited by 100.above; 16th Jul 2010 at 02:32.
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Old 15th Jul 2010, 03:48
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The old saying "the second engine in a piston will only carry you to the crash site"
I’ll leave that comment for others to debate, but suffice to say it is a myth and is certainly so regarding this case. The aircraft is certified to be able to maintain 5000 ft on one engine at MTOW in ISA conditions. On the day it was 11°C colder and 21hPa higher pressure than ISA and well below MTOW.
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Old 15th Jul 2010, 03:50
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100.above

And how have you deduced this from the preliminary report?
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Old 15th Jul 2010, 04:15
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The preliminary report tells nothing new.
Exactly. And the kind of debate currently going on YSRI vs YSBK and why was what got this thread shut down last time...

There is only one person who knows why a return to BK was attempted, and everything else we can postulate here is a guess at best.

I am sure at the time that he thought the best course of action was BK. And i more than likely would have too. More facts (cause of initial failure, power available on remaining engine, A/C not having available height/airspeed/power to get off the back of the drag curve) are required before jumping to conclusions.
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Old 15th Jul 2010, 04:37
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The preliminary report tells nothing new.
Actually it does. We now know for certain where he was, what height he was at when he turned back, times, ROD, speeds, weather (forecast and actual), RT etc. All before was purely speculative at best and that is the reason it was closed down.
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Old 15th Jul 2010, 04:44
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RatsoreA

Quote:
The preliminary report tells nothing new.

Actually it does. We now know for certain where he was, what height he was at when he turned back, times, ROD, speeds, weather (forecast and actual), RT etc. All before was purely speculative at best and that is the reason it was closed down.
Well, yes, and no! And I am not suggesting this be shut down either.

It confirms what most were able to deduce with the little info we had previously. Yes, it certainly clears up the Wx/route/ROD/etc etc.

But I don't think a lot of those (newly highlighted and confirmed??!) facts weren't in contention on this forum.


Disclaimer - Just my opinion!
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Old 15th Jul 2010, 04:57
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Could we PLEASE not have the idiot posts in this thread that resulted in the other one being locked.

I didn't know Andrew (or Kathy) but I hope that through the actions taken by Andrew this thread can be used so that we can all learn something and not end up with the same tragic result.

Why was the aircraft descending at such a rate? I do not know the PA31 but the ROD seems excessive.
Do you think the pilot may have been complying with ATC "instructions" and deliberately descended rather than "drift down" and maintain a height advantage?
0752:12 - ATC instructed the pilot to maintain 5,000 feet.
0754:35 - Soon after, ATC instructed the pilot to descend to 2,500 ft and advised that Richmond airport was two miles to the south of the aircraft if the pilot could not maintain height. The pilot advised that the aircraft was on a ‘slow descent’. At this time, the aircraft was descending through 4,700 ft with a groundspeed of 163 kts.
[I bolded the above]
  • Is 1,000 fpm considered a slow descent in this aircraft with one engine out?
  • Is the height lost during the turn back to Bankstown a reasonable amount to be expected during this time? (Engine checks, shutdown, secure engine etc)
  • What is the Blue Line speed on the PA31?
  • Several witnesses reported hearing a ‘spluttering’ engine sound. Could this spluttering sound have been caused by the throttle being closed for the landing? (keeping in mind that spluttering to us can mean something quite different to non aviators) Again I do not know this aircraft and how it behaves.
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Old 15th Jul 2010, 05:08
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I am still wondering why unsuspecting NSW Health patients are being transported by 30-odd year old light piston-powered twins, when NSW Ambulance (a division of NSW Health) has contracted RFDS with near-new twin-turbine Kingairs sitting at Sydney for that exact task.....?

The busted-arse old Chieftain etc might do the job cheaper, but what is the cost when something like this happens?
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Old 15th Jul 2010, 05:12
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There's plenty of "should haves" in life. This poor little bugger didn't live to regret his.
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Old 15th Jul 2010, 05:12
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Biggles78 Could we PLEASE not have the idiot posts in this thread that resulted in the other one being locked.
You mean like this one -

Jamair I am still wondering why unsuspecting NSW Health patients are being transported by 30-odd year old light piston-powered twins, when NSW Ambulance (a division of NSW Health) has contracted RFDS with near-new twin-turbine Kingairs sitting at Sydney for that exact task.....?

The busted-arse old Chieftain etc might do the job cheaper, but what is the cost when something like this happens?
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Old 15th Jul 2010, 05:20
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Jamair

The aircraft in question might have been 26 years old but it only had 6000 odd hours on the airframe. I wouldn’t call that busted arse. It probably had fewer hours on it than the average RFDS aircraft.
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Old 15th Jul 2010, 05:39
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404 Titan wrote:

I’ll leave that comment for others to debate, but suffice to say it is a myth and is certainly so regarding this case. The aircraft is certified to be able to maintain 5000 ft on one engine at MTOW in ISA conditions. On the day it was 11°C colder and 21hPa higher pressure than ISA and well below MTOW.
Despite the fact that the process under which those aircraft were issued their Type Certification was conducted in excess of thirty plus years ago those airframes are getting very tired now, it very blatantly highlights that some other issue was in play at the time - one that may not have come to light yet.

Like many, I've had my own issues with Pa-31s, mine was minor compared to the one that took the life of Andrew and Karen, but it still struggled even with partial power on the bad one at near MTOW, and that was many, many years ago.

It would be interesting to see just how many aircraft retain their original certified performance these days, and in fact I feel it should be mandatory as part of CASA's ageing aircraft program for each effected airframe to have to re-demonstrate its continued compliance with its original certification standards in order to be re-issed an annual/MR.

RatsoreA, Jamair makes a very valid point. In this day and age there is no place for piston powered dung heaps in Government sponsored/paid for operations, to think otherwise is rather indicative of a Flat Earth mentality.
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Old 15th Jul 2010, 05:43
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Canley Vale plane crash

I have been following the developments in this crash as I was one of the witnesses who saw the plane when it first developed problems over Wilberforce and have a copy of the report released today. I don't have pilot or plane knowledge, but have some basic mechanical knowledge due to my line of work and observed things that I can't pinpoint or find answers for. Is it permissable for me to ask questions here to try and understand further what happened at my end?
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Old 15th Jul 2010, 05:46
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RatsoreA

I think many folk here would think that the post by Jamair has quite a lot of merrit. Unlike yours!

Despite the "shallow fog" and it must have been pretty light, others were doing ILS practice there just prior, what I have learned from this is, in a sick running single, or a engine out twin piston, take the ILS below you, be slightly high on the GS, and hold a stable approach even if its a very shallow fog, because a mostly in control touch down on a large wide runway trumps tracking over suburban Sydney every day.

Note to the above comment: in the case of an engine failing from an unknown fault (i.e may be fuel related for example, rather than oil up the cowls from a broken crank or rod), you need to assume that your remaining engine may not be a sure thing. If its a genuine engine failure and you are 100% sure the other will do the job, then fair enough. It is fair to say in this case neither these two points were clear cut.

No doubt some here will argue this.........

J
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