2 dead in Vic NW of Melb at Wallup
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Don't hold your breath Old Akro, the second half are appendices citing US statistics and spatial disorientation occurences.
So many things were wrong in this crash;
- Pilot recency
- Lack of experience
- Use of seatbelts
- Dark night
- Rain and cloud
- Aircraft overdue for maintenance
Angel Flight need to immediately up their minimum standards as a result of this and rigorously check pilots, as simply relying on people to follow the CASA requirements clearly doesn't and didn't work.
So many things were wrong in this crash;
- Pilot recency
- Lack of experience
- Use of seatbelts
- Dark night
- Rain and cloud
- Aircraft overdue for maintenance
Angel Flight need to immediately up their minimum standards as a result of this and rigorously check pilots, as simply relying on people to follow the CASA requirements clearly doesn't and didn't work.
When you live....
Wing leveler autopilots
Couple of thoughts and observations:
- ATSB has accepted as fait acomplit that the CASR changes are happening today as closing out of the safety issue with recency of NVFR. Now that's not happened - will ATSB review the report and outcomes?
- What I don't understand in all VFR into IMC and similar type reports (this one included) is that the phrase "wing leveling autopilot" is never mentioned. I don't think it unreasonable that the consideration be given to requiring one for NVFR operations. In this and so many other cases, as soon as the pilot lost visual reference, all he had to do was switch it on.
- ATSB has accepted as fait acomplit that the CASR changes are happening today as closing out of the safety issue with recency of NVFR. Now that's not happened - will ATSB review the report and outcomes?
- What I don't understand in all VFR into IMC and similar type reports (this one included) is that the phrase "wing leveling autopilot" is never mentioned. I don't think it unreasonable that the consideration be given to requiring one for NVFR operations. In this and so many other cases, as soon as the pilot lost visual reference, all he had to do was switch it on.
I don't think it unreasonable that the consideration be given to requiring one for NVFR operations. In this and so many other cases, as soon as the pilot lost visual reference, all he had to do was switch it on.
It would be easier to outlaw NVFR. The answer to all this is NOT mandating equipment.
It is a shame they don't comment on the instrument/avionics fit out. The only reference we have for the panel is: "...score marks made by the rotating gyro rotor on the inside of the attitude indictor’s casing indicated that the gyro was rotating at impact..." From personal experience i've found recent panel changes to the regular ride can be disorientating at times.
I wonder how far away the laptop was from the six pack scan ?
"...Analysis of the recorded Global Position System (GPS) data retrieved from the on-board tablet computer identified that..."
"...the effect of the computer’s light level on the pilot’s night vision was unable to be established but it may have been another element that limited the pilot’s vision outside of the cockpit..."
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I wonder how far away the laptop was from the six pack scan ?
"...Analysis of the recorded Global Position System (GPS) data retrieved from the on-board tablet computer identified that..."
"...the effect of the computer’s light level on the pilot’s night vision was unable to be established but it may have been another element that limited the pilot’s vision outside of the cockpit..."
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The pilot clearly was not current for the intended operation.
Solve that problem and the issues all go away. You don't need additional equipment to fly NVFR or IFR.
Solve that problem and the issues all go away. You don't need additional equipment to fly NVFR or IFR.
Just had a read of the report. Quite a sobering read, a tale of poor judgement and decision making and perhaps a cavalier attitude to details and regulations.
The aircraft was 9 hrs past its maintenance release expiry. This is not a small overfly by 0.5. 9 hrs represents multiple flights. In my experience, pilots who are slack in one area, and I mean very slack, usually show up major deficiencies in other areas too.
A low overcast over a sparsely lit area is .......IMC. No ifs, buts or maybeys. Its no place for anyone with only NVR rating, limited recency in NVFR and in a non_IFR aircraft. To compound matters, that period before EOD where its not quite daylight, but night quite darkness is a real danger zone. It can be impossible to pick out ground lights if they are there in the first place. An iPad on the yoke or instrument panel turned up to full brightness can reduce your vision out the front window by a frightening degree.
The aircraft was 9 hrs past its maintenance release expiry. This is not a small overfly by 0.5. 9 hrs represents multiple flights. In my experience, pilots who are slack in one area, and I mean very slack, usually show up major deficiencies in other areas too.
A low overcast over a sparsely lit area is .......IMC. No ifs, buts or maybeys. Its no place for anyone with only NVR rating, limited recency in NVFR and in a non_IFR aircraft. To compound matters, that period before EOD where its not quite daylight, but night quite darkness is a real danger zone. It can be impossible to pick out ground lights if they are there in the first place. An iPad on the yoke or instrument panel turned up to full brightness can reduce your vision out the front window by a frightening degree.
via nomorecatering:
...a read of the report. Quite a sobering read, a tale of poor judgement and decision making and perhaps a cavalier attitude to details and regulations.
...a read of the report. Quite a sobering read, a tale of poor judgement and decision making and perhaps a cavalier attitude to details and regulations.
From the report, Pg 19: "The pilot was reported to be cautious in his operational decision making when deteriorating weather conditions were forecast. He had cancelled a number of previous Angel Flights due to poor weather. All but one of those flights was cancelled prior to its commencement, with the other one being cancelled airborne as the pilot repositioned to collect his passengers..."
The computer he had has me wondering...
Pg 19: "...increased workload and detrimental effect on identifying external visual cues associated with using the computer and possible distraction associated with reflected light, would have increased the likelihood for that to occur..."
Was this computer a new toy and being used for the first time ? New electronic bling in the cockpit can be very distracting and cause fixation at the wrong time. Had he used a computer at night before ?
An out of date maintenance release could be a one-off for this pilot. We don't know from the report.
http://www.atsb.gov.au/media/4462266...-100_final.pdf
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I am going to be harsh. Aussie Bob you are right, there is no sense in legislating this or that. Or anything else. You can't legislate out stupid. What this guy did was stupid.
Give him a wing leveller or an EFIS with SV, he could well have just pushed further into trouble before he crashed. Maybe he would have gotten out of trouble but he had no right being there in the first place.
Everyone now suffers from knee jerk reactions.
Flying in GA is not that dangerous if you remove a whole number of dumb actions. The saying goes don't do something that would look dumb in the NTSB report. Remove those things and the safety stats start looking stunningly better.
Knee jerk ranting over for now…off to read the report. Yes I know Ready, Fire, Aim.
Give him a wing leveller or an EFIS with SV, he could well have just pushed further into trouble before he crashed. Maybe he would have gotten out of trouble but he had no right being there in the first place.
Everyone now suffers from knee jerk reactions.
Flying in GA is not that dangerous if you remove a whole number of dumb actions. The saying goes don't do something that would look dumb in the NTSB report. Remove those things and the safety stats start looking stunningly better.
Knee jerk ranting over for now…off to read the report. Yes I know Ready, Fire, Aim.
Probably belongs in another thread, but for me this highlights the issue with regulatory reform in this country:
So - in October 2002, ATsB issues a fairly broad-based recommendation covering several areas (not just competency). With amazing alacrity, CAsA responds in December with a firm commitment to develop a draft competency standard - and Part 61, 11 years on, is still not a reality, and would not address the 2002 ATsB recommendation anyway.
We need to learn from this tragedy, I couldn't help but think the PIC made a whole lot of sensible decisions - landing at Bendigo presumably due to weather concerns, accessing NAIPS there to confirm, subsequently diverting to the north - I could maybe see myself making similar decisions in the circumstances. Maybe I might have focussed more on last light, maybe not, who knows (now I will). And I can accept Jaba's view above - but we need to understand what led him into this situation, when prior to that he seemed to take a conservative approach.
Unfortunately, the ATsB report gives us as practitioners precious little guidance on how we may avoid a similar fate.
And CAsA, as usual, is dragging the regulatory chain.
During its investigation the ATSB identified a safety issue in respect of the requirements for pilots to maintain currency, recency and proficiency for night VFR flight under dark night conditions. In consequence, on 23 October 2002, the ATSB issued safety recommendation R20020193 that stated:
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority (CASA) review the general operational requirements, training requirements, flight planning requirements and guidance material provided to pilots conducting VFR operations in dark night conditions.
In response to this recommendation, on 13 December 2002, CASA advised that:
CASA acknowledges the intent of this Recommendation. As part of the proposed CASR Part 61, CASA is developing the requirements for night VFR ratings which will be based on the existing Civil Aviation Order CAO 40.2.2. In addition, a draft competency standard for night visual flight operations has been developed for inclusion in the proposed CASR Part 61 Manual of Standards.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority (CASA) review the general operational requirements, training requirements, flight planning requirements and guidance material provided to pilots conducting VFR operations in dark night conditions.
In response to this recommendation, on 13 December 2002, CASA advised that:
CASA acknowledges the intent of this Recommendation. As part of the proposed CASR Part 61, CASA is developing the requirements for night VFR ratings which will be based on the existing Civil Aviation Order CAO 40.2.2. In addition, a draft competency standard for night visual flight operations has been developed for inclusion in the proposed CASR Part 61 Manual of Standards.
We need to learn from this tragedy, I couldn't help but think the PIC made a whole lot of sensible decisions - landing at Bendigo presumably due to weather concerns, accessing NAIPS there to confirm, subsequently diverting to the north - I could maybe see myself making similar decisions in the circumstances. Maybe I might have focussed more on last light, maybe not, who knows (now I will). And I can accept Jaba's view above - but we need to understand what led him into this situation, when prior to that he seemed to take a conservative approach.
Unfortunately, the ATsB report gives us as practitioners precious little guidance on how we may avoid a similar fate.
And CAsA, as usual, is dragging the regulatory chain.
Interesting having a look at the aircraft track on page 2 of the report.
I see the aircraft was fairly near to a straight track untill Wallop (cloud blocking perhaps), then the track goes south towards Horsham, then, probably due to it being clearer, heads of to Nhill. Musta been a lot of head down time on that GPS computer.
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I see the aircraft was fairly near to a straight track untill Wallop (cloud blocking perhaps), then the track goes south towards Horsham, then, probably due to it being clearer, heads of to Nhill. Musta been a lot of head down time on that GPS computer.
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Firstly, it looks like CASA forgot to tell the ATSB that the Dec 4 changes to licencing have been put off. Getting this wrong on the first page of a report issued 14 days after the announced deferment is just plain amateur.
Secondly, it just reads like an undergrad student report who doesn't quite get it. I wonder if the author has actually flown in a light aircraft.
Thirdly, this accident occurred 5 minutes BEFORE last light. Most of the diatribe about NVFR is simply not relevant. Furthermore, the PIC had a night check flight with an instructor 31 days before the accident. He met even the ATSB's recommendations for tighter NVFR currency.
Fourthly, this report continues the unacceptable practice of previous reports by not tabling any primary data. It does not append a copy of the actual weather report - it only contains the ATSB's own paraphrasing of the report. It does not examine if the weather report received at Bendigo had any changes from the one received before departure from Essendon. What happened at Bendigo that encouraged him to continue?
The flightpath from Wallop onwards is a bit bizarre and is probably consistent with the pilot becoming unsure of his position. The final report mentions only the tablet PC GPS guidance. However, the preliminary report notes that the aircraft had a Lowrance 2000c GPS panel mounted in the aircraft. If the tablet was being used as the primary navigation device (not countenanced in 2011) then it can be imagined that he became disoriented while looking at the tablet. But how do we know if it or the Lowrance was being used as the primary navigation guidance device? One would reach a different conclusion if it was the Lowrance. Was the Lowrance database up to date? Why was it presence mentioned in the preliminary report and not the final report? What was the tablet? What software was in using? Was the software up to date? All important questions that remain un-asked by this report. Note: this accident occurred before OZRUNWAYS, etc was legal as in flight reference.
The report note "that a cold front was moving across the west of Victoria", but doesn't position the aircraft in relation to the front. The report included emotive, subjective language like "...had been a terrible day" (p3), but if the front had passed the weather behind may have been significantly better. What is the purpose of quoting such emotive, qualitative and potentially irrelevant comments? A IFR pilot flying to Warracknabeal is quoted commenting on cloud cover, but the report fails to state what altitude he was flying. It may well have been 6000 ft (ICAO level above LSALT to Hamilton) or more, in which case his experience would have been completely differen and of limited relevance.
The preliminary report lists METAR data for Horsham at the time, but the final report omits it. Why? The Horsham METAR doesn't fit all that well with the tale that the ATSB weaves. Is this why?
As noted by Jaba (I think), the report does not tell us if the aircraft had any sort of autopilot. Once again, this is pretty important information.
If the aircraft had been able to fly direct from Wallop to Nhill it may well have landed in diminishing visibility before published light light. The real question is why the flight path became so erratic.
And I struggle to see that a NVMC rated pilot with a 1.5 hour check flight with an instructor only a month before would lose control after a handful of minutes in poor visibility before published last light.
Its an extraordinarily sad accident. The pilot appears to have had a number of lapses in judgement, but none should have resulted in this accident.
Secondly, it just reads like an undergrad student report who doesn't quite get it. I wonder if the author has actually flown in a light aircraft.
Thirdly, this accident occurred 5 minutes BEFORE last light. Most of the diatribe about NVFR is simply not relevant. Furthermore, the PIC had a night check flight with an instructor 31 days before the accident. He met even the ATSB's recommendations for tighter NVFR currency.
Fourthly, this report continues the unacceptable practice of previous reports by not tabling any primary data. It does not append a copy of the actual weather report - it only contains the ATSB's own paraphrasing of the report. It does not examine if the weather report received at Bendigo had any changes from the one received before departure from Essendon. What happened at Bendigo that encouraged him to continue?
The flightpath from Wallop onwards is a bit bizarre and is probably consistent with the pilot becoming unsure of his position. The final report mentions only the tablet PC GPS guidance. However, the preliminary report notes that the aircraft had a Lowrance 2000c GPS panel mounted in the aircraft. If the tablet was being used as the primary navigation device (not countenanced in 2011) then it can be imagined that he became disoriented while looking at the tablet. But how do we know if it or the Lowrance was being used as the primary navigation guidance device? One would reach a different conclusion if it was the Lowrance. Was the Lowrance database up to date? Why was it presence mentioned in the preliminary report and not the final report? What was the tablet? What software was in using? Was the software up to date? All important questions that remain un-asked by this report. Note: this accident occurred before OZRUNWAYS, etc was legal as in flight reference.
The report note "that a cold front was moving across the west of Victoria", but doesn't position the aircraft in relation to the front. The report included emotive, subjective language like "...had been a terrible day" (p3), but if the front had passed the weather behind may have been significantly better. What is the purpose of quoting such emotive, qualitative and potentially irrelevant comments? A IFR pilot flying to Warracknabeal is quoted commenting on cloud cover, but the report fails to state what altitude he was flying. It may well have been 6000 ft (ICAO level above LSALT to Hamilton) or more, in which case his experience would have been completely differen and of limited relevance.
The preliminary report lists METAR data for Horsham at the time, but the final report omits it. Why? The Horsham METAR doesn't fit all that well with the tale that the ATSB weaves. Is this why?
As noted by Jaba (I think), the report does not tell us if the aircraft had any sort of autopilot. Once again, this is pretty important information.
If the aircraft had been able to fly direct from Wallop to Nhill it may well have landed in diminishing visibility before published light light. The real question is why the flight path became so erratic.
And I struggle to see that a NVMC rated pilot with a 1.5 hour check flight with an instructor only a month before would lose control after a handful of minutes in poor visibility before published last light.
Its an extraordinarily sad accident. The pilot appears to have had a number of lapses in judgement, but none should have resulted in this accident.
Last edited by Old Akro; 3rd Dec 2013 at 12:42. Reason: spelling
Angel Flight need to immediately up their minimum standards as a result of this and rigorously check pilots, as simply relying on people to follow the CASA requirements clearly doesn't and didn't work.
The report looks at the conduct of Angel Flight on pages 9&10. I would suggest that the comparison with 10 North American Angel Flight organisations shows the Australian operation to be pretty much at best practice. Can we say the same of CASA?
There is another issue which deserves to be discussed - at least enough to discount it. Most of the discussion is about the pilot's errors & weaknesses. Flying Magazine (US) currently has an interesting blog on why pilots vilify pilots
Why Pilots Love to Vilify Other Pilots | Flying Magazine
Without meaning any disrespect, or making any accusations, I would think that an accident report that considers all the possible causes might also ask if the passenger seat belt being undone and the erratic flight path are related. The report says the passengers were nervous. Nervous passengers generally tighten seat belts, not undo them. Did a passenger have a panic attack and disrupt / distract the pilot? Did a passenger grab the controls? Why wouldn't a creditable report consider this - even if only to dismiss it?
Why Pilots Love to Vilify Other Pilots | Flying Magazine
Without meaning any disrespect, or making any accusations, I would think that an accident report that considers all the possible causes might also ask if the passenger seat belt being undone and the erratic flight path are related. The report says the passengers were nervous. Nervous passengers generally tighten seat belts, not undo them. Did a passenger have a panic attack and disrupt / distract the pilot? Did a passenger grab the controls? Why wouldn't a creditable report consider this - even if only to dismiss it?
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If the tablet was being used as the primary navigation device (not countenanced in 2011) then it can be imagined that he became disoriented while looking at the tablet.
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Old Akro,
The lack of relevance re. NVFR is only so because it seems fairly clear that effectively this poor fellow was actually working to the same level as a bad wx night IFR circling approach pilot would be at a remote strip. That is no cake walk even for a seasoned driver. The last 10 minutes of this flight would be nothing like what NVFR is intended to be, instead it was real dark with low cloud and rain. That's IFR.
I don't and given the information supplied in the report the outcome has few surprises.
Thirdly, this accident occurred 5 minutes BEFORE last light. Most of the diatribe about NVFR is simply not relevant. Furthermore, the PIC had a night check flight with an instructor 31 days before the accident. He met even the ATSB's recommendations for tighter NVFR currency.
And I struggle to see that a NVMC rated pilot with a 1.5 hour check flight with an instructor only a month before would lose control after a handful of minutes in poor visibility before published last light.
Wing leveller won't actuate if you are already in a spiral dive.
Interestingly the ATSB has selectively chosen to plot rate of change of altitude but not altitude. This shows both ascent & descent. Once again this does not support a spiral dive. Similarly, it plots rate of change of airspeed, but not airspeed, but there is no trend of continuously increasing airspeed as occurs in a spiral dive.
If this aircraft had an autopilot, its most likely to be a Piper Altimatic 2 with heading hold.
My main point is that a diligent report would cover this.
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And I struggle to see that a NVMC rated pilot with a 1.5 hour check flight with an instructor only a month before would lose control after a handful of minutes in poor visibility before published last light.
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How many NVFR pilots have actual experience with No moon, dark night ops? i know a few in the Sydney region who have never left the Sydney basin or central coast lights doing a NVFR rating. NVFR outside metro areas is essentially IFR and should be treated and taught as such.
and the crash site suggests to me he hit thr ground in a relative wings level attitude. if in a spiral dive, the wreckage would be over a smaller area.
IMO, he was scud running, and in dark condidtions, lost sight of terrain. sure, it was 5 mins before last light, but 5 mins before last light on a cloudy overcast day still gets dark enough to be considered night..
and the crash site suggests to me he hit thr ground in a relative wings level attitude. if in a spiral dive, the wreckage would be over a smaller area.
IMO, he was scud running, and in dark condidtions, lost sight of terrain. sure, it was 5 mins before last light, but 5 mins before last light on a cloudy overcast day still gets dark enough to be considered night..
Heres a link to old BOM radar loops.
Somebody who knows how to take a screen shot picture might be able to post it here.
BoM Melbourne Radar Loop - Rain Rate - IDR023
Somebody who knows how to take a screen shot picture might be able to post it here.
BoM Melbourne Radar Loop - Rain Rate - IDR023
Last edited by Flying Binghi; 3rd Dec 2013 at 21:34. Reason: correct link