Coroners Finding on 2013 Glider Fatality
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Don't blame them, train them.
Eyrie – a proper SMS would define the nature of the accidents you mention. It's a little difficult to truly identify the factors which led up to the events mentioned – without all the details, so it'll have to be a broad brush discussion. But, no matter the 'why and how' of an accident I believe the key is education. The old saw 'don't blame them, train them' is a truism. Take the Keepit event, it is not enough to state that all the runway should be used.
The reasons why the tow was abandoned, why was the take off path was fence obstructed and why the obvious risk was not reduced need definition. It seems to me (and I'll own I know little of glider launching) that the risk of a low, slow abandoned launch would imply that if the aircraft can't safely 'go', then it must be able to safely 'stop', i.e. land straight ahead, at least until it has enough height/speed to work with. That takes us into 'skill levels' – what an experienced instructor pilot can safely manage, is probably not achievable by a neophyte. So, if we can learn to take the fence out of the equation, we can reduce the low level 'disconnect' abandoned tow risks and explain the why of it to the troops.
But if no one else, bar you and I, know it then the research is wasted and the event can reoccur. The easy part is to draft rules which prohibit and restrict, the tough part is writing a rule set which allows for the operation – but mitigates the risk. From that rule a SOP can be developed for the airfield in question. Say one take off direction took you over a vineyard at low level, this is not a place you'd want to land in – so the SOP for that direction would be drafted to reflect the increased risk level and perhaps restrict. It's basically applied common sense - until it gets lost in the regulatory jungle.
It is not difficult at all these days to make a 'short' briefing video, pop it up on "U bend tube" and email the members to let them know it exists. Take all the lessons from Keepit explain them and suggest strategy to mitigate or avoid a repeat; get the troops thinking and aware. It would take a day to script it and a Saturday morning to do it; and, I am certain there's enough wit and talent in the ranks of the GFA to get it done. Sort of a poor mans crash comic to get the information out there, where it belongs. Use some CASA's ill gotten gains – ask 'em for 'more' if you need it; don't worry - they have plenty.
Risk management – not, repeat not rocket science. Murphy, the Fools Rule, Sods Law of the Ocean, gods willing and weather permitting cannot ever be 'mitigated' out of the game; you can make 10,000 rules and Murphy will invent object lesson 10,001, just to prove a point.
Forky & LookinDown make a valid argument and reflect what I have always believed of GFA. But, looking back over the submissions to the WLR (ASRR) and Eyrie's offerings – it seems there is 'trouble at mill'. Shirley men of good intentions and a common purpose can sort it out over a beer (or two), be a shame to see the fine record of a great organisation fall victim to in house wrangling and hair pulling – lots of examples of that.
I'll have two bob's worth of no agenda,....Oh, and one of those 'T' shirts please.....
Toot toot..
The reasons why the tow was abandoned, why was the take off path was fence obstructed and why the obvious risk was not reduced need definition. It seems to me (and I'll own I know little of glider launching) that the risk of a low, slow abandoned launch would imply that if the aircraft can't safely 'go', then it must be able to safely 'stop', i.e. land straight ahead, at least until it has enough height/speed to work with. That takes us into 'skill levels' – what an experienced instructor pilot can safely manage, is probably not achievable by a neophyte. So, if we can learn to take the fence out of the equation, we can reduce the low level 'disconnect' abandoned tow risks and explain the why of it to the troops.
But if no one else, bar you and I, know it then the research is wasted and the event can reoccur. The easy part is to draft rules which prohibit and restrict, the tough part is writing a rule set which allows for the operation – but mitigates the risk. From that rule a SOP can be developed for the airfield in question. Say one take off direction took you over a vineyard at low level, this is not a place you'd want to land in – so the SOP for that direction would be drafted to reflect the increased risk level and perhaps restrict. It's basically applied common sense - until it gets lost in the regulatory jungle.
It is not difficult at all these days to make a 'short' briefing video, pop it up on "U bend tube" and email the members to let them know it exists. Take all the lessons from Keepit explain them and suggest strategy to mitigate or avoid a repeat; get the troops thinking and aware. It would take a day to script it and a Saturday morning to do it; and, I am certain there's enough wit and talent in the ranks of the GFA to get it done. Sort of a poor mans crash comic to get the information out there, where it belongs. Use some CASA's ill gotten gains – ask 'em for 'more' if you need it; don't worry - they have plenty.
Risk management – not, repeat not rocket science. Murphy, the Fools Rule, Sods Law of the Ocean, gods willing and weather permitting cannot ever be 'mitigated' out of the game; you can make 10,000 rules and Murphy will invent object lesson 10,001, just to prove a point.
Forky & LookinDown make a valid argument and reflect what I have always believed of GFA. But, looking back over the submissions to the WLR (ASRR) and Eyrie's offerings – it seems there is 'trouble at mill'. Shirley men of good intentions and a common purpose can sort it out over a beer (or two), be a shame to see the fine record of a great organisation fall victim to in house wrangling and hair pulling – lots of examples of that.
I'll have two bob's worth of no agenda,....Oh, and one of those 'T' shirts please.....
Toot toot..
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I normally don't coment on such things but it seams now more of a cya operation in progress.
The loss of simple airmanship has resulted in the loss of a life.
They will now factor in human resources etc and then something else when simple common sence is all that is required.
Most airports now demend that a simple taxy requires a radio cleareance that not even to leave the ground.
What has to be asked is what happened to airmanship. Simple radio calls.
It's a sad indictment on the GfA really.
Not being envied but I bet there is a lot of politics involed at the higher level of GfA.
The loss of simple airmanship has resulted in the loss of a life.
They will now factor in human resources etc and then something else when simple common sence is all that is required.
Most airports now demend that a simple taxy requires a radio cleareance that not even to leave the ground.
What has to be asked is what happened to airmanship. Simple radio calls.
It's a sad indictment on the GfA really.
Not being envied but I bet there is a lot of politics involed at the higher level of GfA.
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Good question
yr right - that is certainly a good question and I agree there is a cya operation going on.
You are also correct about AIRMANSHIP.
The coroner seems to have been bamboozled into worrying about radios, radio calls etc.
Nobody here would taxi onto a runway by just relying on radio calls or lack of receipt of one without having a GOOD LOOK would they?
Same with launching a glider. There is part of the standard pre-takeoff check called "OUTSIDE?" and the response from the person hooking on or running the wingtip is "ALL CLEAR ABOVE AND BEHIND", if that is indeed the case or "WE'LL HAVE TO WAIT FOR THE LANDING AIRCRAFT etc " if it isn't. Most gliders have poor rearward visibility when the pilot is strapped in so the person outside assisting with the launch does this. If there is a line of trees obscuring a possible approach path???????
kharon, I agree completely about risk management.
Before that though it would be nice just to have distributed an objective report from the powers that be that an accident has occurred and the basic objective facts (see NTSB reports for example). Later a thorough discussion of the lessons to be learned. This doesn't happen in the GFA nowadays. Instead some new rules will be made which likely don't address the real issue.*
One bloke I know wrote an article about gliding safety for the official magazine after he had had a serious accident in a glider that easily could have killed him. It was very mildly critical of GFA policy and was knocked back for publication.
That is what you get when you have a heirarchical top down organisation that communicates in only one direction and doesn't consult. (Sound like another organisation we all know and love?).
LookinDown is confusing reams of paperwork procedures and manuals/cya with having a airmanship/safety culture. Bit like CASA really. Just check the accident record over the last decade, mate. Note the bad ones with instructors in the aircraft.
* here's a little story that happened a long time ago. There is a glider, the H201 Libelle that has a really neat and elegant aileron drive mechanism that is hidden entirely within the wing profile.
Unfortunately if you take them out of both wings at the same time and put them back swapped the ailerons work in reverse.
One of the type had this happen during maintenance. The bloke who later rigged it to fly it (and presumably did the Daily Inspection) was told he wasn't current enough to do a test flight so another bloke was whistled up. He jumped in and around 40 knots at liftoff when the wing was still firmly on the ground he released the towrope and did a nice cartwheel which wrote off the glider, fortunately without hurting himself. The third bloke to look at the wreckage (the pilot was complaining the ailerons didn't work) picked that they were working backwards.
So the fact that this could happen was disseminated (this was a long time ago) and steps were taken to require the parts to be painted red and green with matching marks on the structure.
What wasn't figured out was that clearly checks weren't being done properly.
Again, part of the pre takeoff check is to stand next to the cockpit before getting in, check for full and free movement of the controls and IN THE CORRECT SENSE. Full and free is checked again after strapping in.
So about 14 years later it happened again in Australia with similar results.
About 4 years after that I was strapped in to a glider in NZ when I saw the H201 Libelle in front of me have two attempts at taking off. In both the wing was firmly on the ground. By this time I was unstrapping and as the guy was being pushed off I asked if he wanted to go again in front of me. He said he's think about it so I asked if it had just had maintenance - yep just had a major re-furbish. We went over and I demonstrated the reversed ailerons. Kiwi glider pilots don't do checks properly either! The maintainer is supposed to rig the glider and check the controls properly too, in both countries.
You are also correct about AIRMANSHIP.
The coroner seems to have been bamboozled into worrying about radios, radio calls etc.
Nobody here would taxi onto a runway by just relying on radio calls or lack of receipt of one without having a GOOD LOOK would they?
Same with launching a glider. There is part of the standard pre-takeoff check called "OUTSIDE?" and the response from the person hooking on or running the wingtip is "ALL CLEAR ABOVE AND BEHIND", if that is indeed the case or "WE'LL HAVE TO WAIT FOR THE LANDING AIRCRAFT etc " if it isn't. Most gliders have poor rearward visibility when the pilot is strapped in so the person outside assisting with the launch does this. If there is a line of trees obscuring a possible approach path???????
kharon, I agree completely about risk management.
Before that though it would be nice just to have distributed an objective report from the powers that be that an accident has occurred and the basic objective facts (see NTSB reports for example). Later a thorough discussion of the lessons to be learned. This doesn't happen in the GFA nowadays. Instead some new rules will be made which likely don't address the real issue.*
One bloke I know wrote an article about gliding safety for the official magazine after he had had a serious accident in a glider that easily could have killed him. It was very mildly critical of GFA policy and was knocked back for publication.
That is what you get when you have a heirarchical top down organisation that communicates in only one direction and doesn't consult. (Sound like another organisation we all know and love?).
LookinDown is confusing reams of paperwork procedures and manuals/cya with having a airmanship/safety culture. Bit like CASA really. Just check the accident record over the last decade, mate. Note the bad ones with instructors in the aircraft.
* here's a little story that happened a long time ago. There is a glider, the H201 Libelle that has a really neat and elegant aileron drive mechanism that is hidden entirely within the wing profile.
Unfortunately if you take them out of both wings at the same time and put them back swapped the ailerons work in reverse.
One of the type had this happen during maintenance. The bloke who later rigged it to fly it (and presumably did the Daily Inspection) was told he wasn't current enough to do a test flight so another bloke was whistled up. He jumped in and around 40 knots at liftoff when the wing was still firmly on the ground he released the towrope and did a nice cartwheel which wrote off the glider, fortunately without hurting himself. The third bloke to look at the wreckage (the pilot was complaining the ailerons didn't work) picked that they were working backwards.
So the fact that this could happen was disseminated (this was a long time ago) and steps were taken to require the parts to be painted red and green with matching marks on the structure.
What wasn't figured out was that clearly checks weren't being done properly.
Again, part of the pre takeoff check is to stand next to the cockpit before getting in, check for full and free movement of the controls and IN THE CORRECT SENSE. Full and free is checked again after strapping in.
So about 14 years later it happened again in Australia with similar results.
About 4 years after that I was strapped in to a glider in NZ when I saw the H201 Libelle in front of me have two attempts at taking off. In both the wing was firmly on the ground. By this time I was unstrapping and as the guy was being pushed off I asked if he wanted to go again in front of me. He said he's think about it so I asked if it had just had maintenance - yep just had a major re-furbish. We went over and I demonstrated the reversed ailerons. Kiwi glider pilots don't do checks properly either! The maintainer is supposed to rig the glider and check the controls properly too, in both countries.
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Post-maintenance flights are always an exciting journey of discovery of the various ways in which the maintainers have tried to surprise and kill you.
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Is it legal to carry a passenger on a post maintenance test/check flight?
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For a start it is not a test flight. It is a flight test totally different. And jack I guess you can't read. I've said on numerous occasions that I won't give out an aircraft I won't fly in myself. Second is that there are a lot of pilots I won't fly with. And when maintence accidents are the ame as pilot error I guess I won't fly !!!
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On April 27, 2013, at Southern Tablelands Gliding club, a glider on approach hits a glider being winch launched. Evidently the person responsible for giving the up slack did not look out properly or was unable to see the glider on approach in time to stop the launch. The mid air collision caused damage to the tail of the glider being launched, resulting in the death of its pilot.
Only 7 people on the field, only two gliders being flown. And on only one runway was the grass cut short enough to be usable.
This is what I have gathered from reading the 3 pages of this thread, begun in response to the recent report of the coroner.
Such a terrible accident must be devastating for the club and everyone involved. Whenever anyone is injured or killed it is not easy to accept personal or group responsibility. People react in very different ways. Some say "not my fault!" Some simply leave and never come back. And some are devastated for years.
If the gliding club still exists at Southern Tablelands, I would like to know what changes have been made to prevent a recurrence. We are fortunate enough at our club in the UK to have wide grass runways that can cope with lots of gliders landing more or less at the same time. As far as a winch launch taking off at the wrong time, that happened once at the same time I was airtowing a glider, and only luck kept me from being sliced up by the wire.
There will always be the possibility of the wingtip holder not being qualified or not doing a good lookout. It is best to have TWO people doing the lookout, one is on the wingtip of the glider ready for launch, the other one is doing the radio and should ALSO be having a jolly good lookout for aircraft on approach. Thats how we try to do it, but it does take at least two knowlegable people on the ground. And of course the pilot on approach should also have his eyes on stalks, and the choice of more than one place to plonk the glider.
Only 7 people on the field, only two gliders being flown. And on only one runway was the grass cut short enough to be usable.
This is what I have gathered from reading the 3 pages of this thread, begun in response to the recent report of the coroner.
Such a terrible accident must be devastating for the club and everyone involved. Whenever anyone is injured or killed it is not easy to accept personal or group responsibility. People react in very different ways. Some say "not my fault!" Some simply leave and never come back. And some are devastated for years.
If the gliding club still exists at Southern Tablelands, I would like to know what changes have been made to prevent a recurrence. We are fortunate enough at our club in the UK to have wide grass runways that can cope with lots of gliders landing more or less at the same time. As far as a winch launch taking off at the wrong time, that happened once at the same time I was airtowing a glider, and only luck kept me from being sliced up by the wire.
There will always be the possibility of the wingtip holder not being qualified or not doing a good lookout. It is best to have TWO people doing the lookout, one is on the wingtip of the glider ready for launch, the other one is doing the radio and should ALSO be having a jolly good lookout for aircraft on approach. Thats how we try to do it, but it does take at least two knowlegable people on the ground. And of course the pilot on approach should also have his eyes on stalks, and the choice of more than one place to plonk the glider.
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Thank you for the photo, Andy! This classic safety device is always carried in our Syndicate T21, which has 14 owners. It is quite effective in warning the sleepy ground crew of an impending arrival.
Man Bilong Balus long PNG
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Must admit that the mere fact that the accident occurred has me somewhat puzzled.
At my old Gliding Club where winch launching was the only method used for club ops. Once the Glider was ready for launching with cable hooked on, before the wings were levelled and the 'Take up slack' command given, the wing runner called out to the Pilot
'Canopy closed and locked? to which the pilot had to visually and physically check and read back.
Airbrakes closed and locked? was the next call and the Pilot reacted and responded.
The wingtip runner then looked overhead and behind him, panning to base and downwind, visually checking for traffic and if clear called out
All clear above and behind and then and only then levelled the wings and gave the take up slack command to the winch radio operator.
I was under the impression that this was supposed to be standard procedure at all Gliding Clubs in Australia!
The above mentioned procedures were SOP at my old Club anyway, and this was back in the 1970's.
G'day Mary. Think I met you somewhere here in Aussie back in the 80's. Cannot remember now. Too many Red wines.
At my old Gliding Club where winch launching was the only method used for club ops. Once the Glider was ready for launching with cable hooked on, before the wings were levelled and the 'Take up slack' command given, the wing runner called out to the Pilot
'Canopy closed and locked? to which the pilot had to visually and physically check and read back.
Airbrakes closed and locked? was the next call and the Pilot reacted and responded.
The wingtip runner then looked overhead and behind him, panning to base and downwind, visually checking for traffic and if clear called out
All clear above and behind and then and only then levelled the wings and gave the take up slack command to the winch radio operator.
I was under the impression that this was supposed to be standard procedure at all Gliding Clubs in Australia!
The above mentioned procedures were SOP at my old Club anyway, and this was back in the 1970's.
G'day Mary. Think I met you somewhere here in Aussie back in the 80's. Cannot remember now. Too many Red wines.
