Barry Hempel Inquest
I agree with you K in regards to CAR 206, it indeed has been done to death. If anything the Willowbank Inquest findings once again highlight the absurdity of CAR 206 and its application in the real world.
However the point should not be lost that in both Hempel and Willowbank the regulator was negligent in its duty to uphold the principles of the Civil Aviation Act and indeed their own mission/values statement:
If Hempel and Willowbank accidents are examples of how they uphold their mission and values or indeed their 'duty of care' to the unsuspecting punter going for an adventure flight or a tandem jump...then 'God help us!'
However the point should not be lost that in both Hempel and Willowbank the regulator was negligent in its duty to uphold the principles of the Civil Aviation Act and indeed their own mission/values statement:
Our mission
To enhance and promote aviation safety through effective regulation and by encouraging the wider aviation community to embrace and deliver higher standards of safety.
Our values
These are the principles that guide CASA’s internal conduct as well as its relationship with the wider aviation community:
To enhance and promote aviation safety through effective regulation and by encouraging the wider aviation community to embrace and deliver higher standards of safety.
Our values
These are the principles that guide CASA’s internal conduct as well as its relationship with the wider aviation community:
Having read back through this thread I have a few questions in regards to the investigation carried out (or not) into this accident...where's the accident report?
Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident? Or did the regulator take over the investigation? If so where’s their report and why didn’t they defer to the ATSB?
It seems absurd that the one agency that has the expertise and regulatory backing to conduct investigations into transport accidents was left out of the loop.
Although sometimes painstakingly slow the ATSB does (generally) remain objective and unbiased while conducting an investigation, which means that they would not leave anything unexamined that had the potential to be causal to this accident….so what gives with keeping them out of it?
I know, I know, it was a rogue pilot! But does that excuse not investigating a fatal accident properly?
....or have I missed something?
Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident? Or did the regulator take over the investigation? If so where’s their report and why didn’t they defer to the ATSB?
It seems absurd that the one agency that has the expertise and regulatory backing to conduct investigations into transport accidents was left out of the loop.
Although sometimes painstakingly slow the ATSB does (generally) remain objective and unbiased while conducting an investigation, which means that they would not leave anything unexamined that had the potential to be causal to this accident….so what gives with keeping them out of it?
I know, I know, it was a rogue pilot! But does that excuse not investigating a fatal accident properly?
....or have I missed something?
Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident? Or did the regulator take over the investigation? If so where’s their report and why didn’t they defer to the ATSB?
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Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident? Or did the regulator take over the investigation? If so where’s their report and why didn’t they defer to the ATSB?
Seeing ATSB investigated this one, why did they not go to the Hempel's Aviation Yak? There is nothing on the website, not even notification of an occurrence.
The MiG 15UTI, VH-LSN, took off from runway 12 at Canberra Airport with the pilot and one passenger on board. After becoming airborne, the aircraft entered a climbing left turn and levelled at about 1,200 ft above ground level. The pilot advised the tower controller that he was having a minor technical problem and requested a landing. After a short discussion, the aircraft was cleared to land on runway 35. When the aircraft was about 4 km from the threshold of runway 35, it was seen to enter a steep nose-down attitude. The aircraft subsequently impacted the ground and the pilot and passenger were killed. The Bureau of Air Safety Investigation determined that an engine over-temperature occurred. The over-temperature was probably associated with an internal failure of the upper of two engine fuel pumps. The resulting excessive turbine temperatures led to the turbine blades creeping and rubbing on the turbine casing, and heat generated in the tail pipe as a result was then transferred into the fuselage area. Fuel in the fuselage area aft of frame 21, probably from a leaking fuel boost pump, was ignited by the high radiated temperatures in the tank bay. The fire melted and burned the rudder and elevator control tubes and control of the aircraft was lost. The area where the fire occurred was not monitored by over-heat or fire detection devices, and the pilot was therefore probably not aware of the fire.
Date: 13 Mar 1993 Investigation Status: Completed
Time: 1614 EST Investigation Type: Occurrence Investigation
Location: Canberra
State: ACT
Release Date: 20 Jul 1994 Occurrence Category: Accident
Report Status: Final Highest Injury Level: Fatal
The MiG 15UTI, VH-LSN, took off from runway 12 at Canberra Airport with the pilot and one passenger on board. After becoming airborne, the aircraft entered a climbing left turn and levelled at about 1,200 ft above ground level. The pilot advised the tower controller that he was having a minor technical problem and requested a landing. After a short discussion, the aircraft was cleared to land on runway 35. When the aircraft was about 4 km from the threshold of runway 35, it was seen to enter a steep nose-down attitude. The aircraft subsequently impacted the ground and the pilot and passenger were killed. The Bureau of Air Safety Investigation determined that an engine over-temperature occurred. The over-temperature was probably associated with an internal failure of the upper of two engine fuel pumps. The resulting excessive turbine temperatures led to the turbine blades creeping and rubbing on the turbine casing, and heat generated in the tail pipe as a result was then transferred into the fuselage area. Fuel in the fuselage area aft of frame 21, probably from a leaking fuel boost pump, was ignited by the high radiated temperatures in the tank bay. The fire melted and burned the rudder and elevator control tubes and control of the aircraft was lost. The area where the fire occurred was not monitored by over-heat or fire detection devices, and the pilot was therefore probably not aware of the fire.
Date: 13 Mar 1993 Investigation Status: Completed
Time: 1614 EST Investigation Type: Occurrence Investigation
Location: Canberra
State: ACT
Release Date: 20 Jul 1994 Occurrence Category: Accident
Report Status: Final Highest Injury Level: Fatal
Last edited by Fantome; 18th Jun 2012 at 08:36.
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Fantome,
It was only due to the dedicated persistence of the wife of the pilot assisted by a friend who also was an ex-mil fighter pilot and a Mig pilot that this accident received the attention of the authorities that it finally did.
GAGS
E86
It was only due to the dedicated persistence of the wife of the pilot assisted by a friend who also was an ex-mil fighter pilot and a Mig pilot that this accident received the attention of the authorities that it finally did.
GAGS
E86
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Awaited Coronial answers.
Given the difficulties in having an inquest reopened, it may be time to look at some of the interesting issues raised and potential smoking guns.
Given the world wide track record of failure to recover from low level aerobatic manoeuvrers (USA, UK, NZ and Aust) for the type, I expect the investigation presented to the Coroner removed any doubts about these issues as a potential cause of death.
Given the history of control failures and the UK CAA issued AD, I expect the investigation presented to the Coroner would have made him fully aware of these issues, which he will have considered before handing down a finding on the cause of death.
Given the many rumours of trading dodgy parts, I expect the investigation presented to the Coroner would have made him fully aware of these issues, which he will have considered before handing down a report on the cause of death.
See CP post # 141.
Given the robust CASA oversight of AWB, I expect the Coroner would be fully satisfied that the complex relationship between the Administrative and regulatory bodies was robust, transparent, legally approved (for the operations conducted) and did not contribute in any way to the cause of death.
Now here, the regulator has a stellar track record, many cases of endorsements issued by qualified commercially licensed people being pulled, not to mention CIR etc. etc Seems they can and do pretty much as they please in this area, when the spirit moves 'em.
If all of the above boxes have been ticked we are only left with one, possibly two conclusions. For my money:- It would, I believe, be reasonable to ask if this was a protected species case; and, if so, why and by whom ??; at least to eliminate the questions from our enquiries (so to speak). We shall wait and see.
CBW – "Was the aircraft recovered and did it undergo "mechanical failure" testing? If not why not?".
Sarcs - Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident?.
Sarcs - Although the Warbirds were (apparently) the controlling body, did this mean that they also carried out the investigation into this accident?.
Given the history of control failures and the UK CAA issued AD, I expect the investigation presented to the Coroner would have made him fully aware of these issues, which he will have considered before handing down a finding on the cause of death.
Given the many rumours of trading dodgy parts, I expect the investigation presented to the Coroner would have made him fully aware of these issues, which he will have considered before handing down a report on the cause of death.
WiW - A regulatory body's duties are to maintain compliance to a legislated standard and enforce the regulations as required, by whatever legal means necessary. From what you see in the real world and read on here (and other places) CASA have been more than happy to pursue other operators in the past with much vim and vigour, allegedly sometimes for nothing more than paperwork violations.
Given the robust CASA oversight of AWB, I expect the Coroner would be fully satisfied that the complex relationship between the Administrative and regulatory bodies was robust, transparent, legally approved (for the operations conducted) and did not contribute in any way to the cause of death.
DB – "was to commit an offence, with only 7 GA FOI' s in the Brisbane office, how could they have stopped this flight or others like it ?".
Macro - Does this mean that there are a whole group of pilots who might now not be licensed for what they think they should be ???.
Macro - Does this mean that there are a whole group of pilots who might now not be licensed for what they think they should be ???.
If all of the above boxes have been ticked we are only left with one, possibly two conclusions. For my money:- It would, I believe, be reasonable to ask if this was a protected species case; and, if so, why and by whom ??; at least to eliminate the questions from our enquiries (so to speak). We shall wait and see.
Last edited by Kharon; 19th Jun 2012 at 01:33.
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There can be little doubt that CASA have "pet" operators and projects, and you need to look no further than the grounding of Tiger Airlines for their descent below MDA on approach to YMAV.
Have a trawl through the ATSB weekly summaries ATSB link and sooner or later you'll find an incident with an RPT jet that would be equally as life threatening and deserving of similar sanctions. While not identified, they can't all be Tiger (i.e. QF, VB etc).
Another already mentioned here is the determination to bust Quadrio, the cost of which would have been significant. Had that same diligence and determination been directed at Hempel he would have been grounded years ago.
Another thing - I don't believe the discussion (while enlightening) about AOC and Warbirds addresses the root cause of the accident. Hempel was well known to CASA and there is no doubt they were aware of his capacity to ignore the rules.
Put simply, CASA chose to smack him with a feather when they could have wielded a big stick up to and including a custodial sentence. Had they enforced the regulations as they are duty bound to do, this tragedy would not have happened. There is a earlier mention of 7 FOI's in Brisbane - it would only need one of them to sort him out. Go figure!
Have a trawl through the ATSB weekly summaries ATSB link and sooner or later you'll find an incident with an RPT jet that would be equally as life threatening and deserving of similar sanctions. While not identified, they can't all be Tiger (i.e. QF, VB etc).
Another already mentioned here is the determination to bust Quadrio, the cost of which would have been significant. Had that same diligence and determination been directed at Hempel he would have been grounded years ago.
Another thing - I don't believe the discussion (while enlightening) about AOC and Warbirds addresses the root cause of the accident. Hempel was well known to CASA and there is no doubt they were aware of his capacity to ignore the rules.
Put simply, CASA chose to smack him with a feather when they could have wielded a big stick up to and including a custodial sentence. Had they enforced the regulations as they are duty bound to do, this tragedy would not have happened. There is a earlier mention of 7 FOI's in Brisbane - it would only need one of them to sort him out. Go figure!
As one who was threatened by CASA with up to $40k in fines and 8 years gaol for what was, by any stretch of the imagination, a once-in-an-otherwise-blemish-free 30+ years as a pilot, inadvertant and relatively minor breach of the regs - I read this thread and shake my head!
Dr
Dr
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What sort of aircraft does the "Skull" own again??
A YAK, A YAK, A YAK!!!!
Just the old line:
Whose Mum owns a Whirlpool???
and remember, 95% PARTS exchangeable with the NanChang.
Last edited by Up-into-the-air; 19th Jun 2012 at 05:01.
a once-in-an-otherwise-blemish-free 30+ years as a pilot, inadvertant and relatively minor breach of the regs - I read this thread and shake my head!
The thing that gets me with this whole sordid tale is the more that is revealed the more questions are unearthed...the one with the no apparent involvement of the bureau beggars belief!!
Personally if I'd come unstuck and killed myself in my VH registered Yak I'd expect the recognised experts (ATSB) to be sifting through the wreckage...and hopefully joining the dots to see whether I'd stuffed up or that bloody LAME had left his pesky screwdriver inside the tail empennage!!
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Unlicenced Pilots - oh dear oh dear , what a problem !
Kharon,
how many pilots do you reckon are now sh**ing
themselves because they obtained their endorsements from a person who was described in the "Australian" as "a doctor-shopping, law-breaking, medically unfit pilot"
"The Australian" went on to discuss:
absolutely confident right now that CASA will not wilt under the increasing blowtorch of public opinion, and pull a few of those endorsements?
and what about the insurance policies, how many of those will the insurers void for lack of "approved" endorsements????
Wait until the whole Coroner's report is released, the story in "The Australian" barely scratched the surface!
Remember that at least one Insurer had a barrister AND a Queens Council attending the Inquest !
cheerio for now
how many pilots do you reckon are now sh**ing
themselves because they obtained their endorsements from a person who was described in the "Australian" as "a doctor-shopping, law-breaking, medically unfit pilot" "The Australian" went on to discuss:
- a serious breakdown in communications and regulatory systems
- a lack of responsiveness and disclosure by those in aviation who had witnessed his antics.
absolutely confident right now that CASA will not wilt under the increasing blowtorch of public opinion, and pull a few of those endorsements?and what about the insurance policies, how many of those will the insurers void for lack of "approved" endorsements????
Wait until the whole Coroner's report is released, the story in "The Australian" barely scratched the surface!
Remember that at least one Insurer had a barrister AND a Queens Council attending the Inquest !
cheerio for now
whether I'd stuffed up or that bloody LAME had left his pesky screwdriver inside the tail empennage!!
While I concur 100% with all you say M. SARC-COSY, and while your French is not at fault, something else is a tad taut. Granny used to say "reversing back" and " a final tail-piece". (Then of course there's always that thin fine line between charisma and bull**** to put you off your stroke.)
em·pen·nage
NOUN:
The tail assembly of an aircraft, including the horizontal and vertical stabilizers, elevators, and rudder.
ETYMOLOGY:
French, feathers on an arrow, empennage, from empenner, to feather an arrow : en-, in ; see en-1 + penne, feather (from Latin penna; see pet- in Indo-European roots)
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Personally if I'd come unstuck and killed myself in my VH registered Yak I'd expect the recognised experts (ATSB) to be sifting through the wreckage...and hopefully joining the dots to see whether I'd stuffed up or that bloody LAME had left his pesky screwdriver inside the tail empennage!!
If you'd killed yourself and no-one else, despite having a known medical condition that doesn't mix well with flying, it might have fitted into the 'well he was doing what he loved' category of stuff ups. Unless you'd ploughed into a school of course...
If you'd killed a private passenger that would have been a greater cause for concern.
If you'd killed a paying passenger (despite being prohibited from carrying them) who had discovered your operation because you'd continued to advertise a paying passenger service (despite being prohibited from carrying them) and that unfortunate customer had naively expected that an Australian aviation company advertising joyflights was in fact conforming with the regulations and allowed to do so, then the community in general and the relatives of said passenger in particular should expect that the ATSB would as you say, sift through the wreckage and find out what went wrong so all reasonable steps could be taken to prevent a repeat occurence. They should also wonder why a regulator, if it was aware of breaches, did not take all possible steps to prevent those breaches re-occuring before someone ended up dead rather than after, or indeed even then.
Say a person is known to be driving without a license. Say people who know this call the local coppers and say 'X is hooning around in a souped up Commodore even though his license is suspended.' Say the coppers then find X driving his souped up Commodore without a license. What is the expectation? I'm guessing that the majority of people would expect that the local coppers march X down to the station and charge him. It happens regularly. Sure, there's the odd miscreant who drives away from the courthouse on his fifth suspension, but they're usually plastered all over the news and then locked up. What's the diff?
It's not even like the theoretical X was driving a taxi or other commercial vehicle and advertising his 'Souped Up Commie Taxi Service'. Additionally, there are far fewer licensed pilots than car drivers in the country so it should be easier to keep tabs on them. With aviation, nor is there the disconnect between state regs and agencies that makes regulating ground vehicle drivers even more difficult.
a lack of responsiveness and disclosure by those in aviation who had witnessed his antics.
) that calling CASA about breaches is a WOFTAE. Transair has already been mentioned. 
Wait until the whole Coroner's report is released, the story in "The Australian" barely scratched the surface!
Last edited by Worrals in the wilds; 19th Jun 2012 at 11:41.
Fantome my apologies to your Norman brethren, French was never my forte...or is it forté...oh my head hurts (bloody frogs)!!
Worrals top post mate and it does seem that history repeats...like a broken record!
Worrals top post mate and it does seem that history repeats...like a broken record!
Last edited by Sarcs; 19th Jun 2012 at 10:45.
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If you'd killed a paying passenger (despite being prohibited from carrying them) who had discovered your operation because you'd continued to advertise a paying passenger service (despite being prohibited from carrying them) and that unfortunate customer had naively expected that an Australian aviation company advertising joyflights was in fact conforming with the regulations and allowed to do so, then the community in general and the relatives of said passenger in particular should expect that the ATSB would as you say, sift through the wreckage and find out what went wrong so all reasonable steps could be taken to prevent a repeat occurence. They should also wonder why a regulator, if it was aware of breaches, did not take all possible steps to prevent those breaches re-occuring before someone ended up dead rather than after, or indeed even then.
In the YLHR crash, what airline name was displayed in large text down the sides of the Transair aircraft, and what Company name was written on the tickets?
Transair perhaps?