CASA, Coroner's Courts and the Ombudsman

[slats11]

@ Sunfish

Perhaps CASA did not respond because the Coroners recommendations demonstrate that they are pig ignorant about aviation matters and their recommendations are costly, inefficient, pointless and do nothing useful to improve safety?

I'm not sure thats right. It is always difficult contesting the independent referee. Most people hold the Coroner in fairly high regard precisely because of the independence. The Coronial process is sometimes let down by the standard of the various "subject matter experts." Perhaps the industry needs to consider the need for some experts outside CASA & ATSB.

@ Fantome

Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I
have detected a degree of animosity that I consider inimical to a productive,
collaborative focus on air safety. CASA’s submissions in this inquest suggest that there was a danger of the ATSB's recommendations being ignored and I continue
to detect a defensive and less than fulsome response to some of them.

Telling words indeed given what was to happen with PelAir at Norfolk Island.

[LeadSled]

maybe after the next coroners report on this just past fatality, the coroner may just have enough sense to make one very simple and easy to enforce ruling of mandatory fitting of EPIRBS. May not stop people dieing but will speed up the search and recovery process.

Fencehopper,
With the very greatest of respect, you should get your facts straight !!!

If, by EPIRBS, you mean handheld or portable devices, a locator beacon is already mandatory for flight over 50 nm. They have had an excellent in-service record.

If you mean permanently mounted crash locator beacons, forget it, they are a complete waste of time and money, with a greater than 95% failure rate in actual crash scenarios, or 100% if in the water, or there is a serious post crash fire.

The source for my statement ---- examination of the Australian crash record in the 1990's, resulting in the regulations being changed to not mandate such a useless device.

This was confirmed by the statistics that underpinned the CASA post implementation review of the current regulations.

Tootle pip!!

[andrewr]

If, by EPIRBS, you mean handheld or portable devices, a locator beacon is already mandatory for flight over 50 nm. They have had an excellent in-service record.

If you mean permanently mounted crash locator beacons, forget it, they are a complete waste of time and money, with a greater than 95% failure rate in actual crash scenarios, or 100% if in the water, or there is a serious post crash fire.

I am interested to read this study - do you have a link?

What is the rate of activation of PLBs in actual crash situations? Stuff I have read suggests that PLBs also have issues e.g. they can't be reached after the crash, are also destroyed by fire, or there is nobody able to activate them.

I am most interested in crashes where there is a survivor - what is the rate of ELT activation in those cases? There were a couple of cases I found where the ELT failed to activate, a PLB was carried but the survivors were unable to activate it - so these are not really conclusive.

If the ELT fails to activate due to crash damage but there are no survivors I guess thats just the nature of the forces involved. Obviously a PLB is also unlikley to be activated in that case.

[Jabawocky]

andrewr

The idea is that in the event of of a catastrophic crash (non survivable) the ELT/PLB is a moot point.

However, if you are in a bad situation such as S/E engine failure the first thing you do is point it to the best place you can, put the PLB on and perhaps stuff it in your shirt.

If the forced landing is survivable the PLB will certainly survive.

[andrewr]

However, if you are in a bad situation such as S/E engine failure the first thing you do is point it to the best place you can, put the PLB on and perhaps stuff it in your shirt.

Have you ever activated a PLB, or read the instructions for activating one? It's not as simple as pushing a button. They are designed to make accidental activation difficult, not for fast and easy activation.

I know someone who had an engine failure and activated his PLB on instruction frm ATC. He described reading the instructions and working out how to extend the antenna and activate the ELT while setting up for the forced landing. This didn't sound ideal to me.

Also, a number have inbuilt strobes. A strobe inside your shirt (or even just in the cockpit) every 3 seconds probably won't help your forced landing.

I carry a PLB, but I do not expect to activate it in the air. I also have an ELT. If I have time to activate something in the air, it will be the ELT via the switch on the panel. On the ground, I will activate the PLB if able.

[Gabilian]

https://www.atsb.gov.au/media/412662...-128_final.pdf

I'm a firm believer that if you are carrying a PLB that it is carried on your person (typically they have a facility to be carried on your belt) and that you are familiar with the process to activate them. The ones that I am currently familiar with can be activated with one hand.

[andrewr]

https://www.atsb.gov.au/media/412662...-128_final.pdf

"Data from the ATSB database show that ELTs function as intended in about 40 to 60 percent of accidents in which their activation was expected."

"ELT activations have been directly responsible for saving an average of four lives per year."

Not a complete waste of time and money, if you are one of those 4.

[Creampuff]

Please, please (please) don’t start lobbying for a return to mandatory fitment of ELTs to GA aircraft.

The battle was hard fought, and won, on the basis of objective data, not strongly-held opinions.

"Data from the ATSB database show that ELTs function as intended in about 40 to 60 percent of accidents in which their activation was expected."

"ELT activations have been directly responsible for saving an average of four lives per year."

Not a complete waste of time and money, if you are one of those 4.

*sigh*

How many pilot/pax lives have been saved through PLB activations, which lives would not have been saved if the pilot/pax had no PLB and instead been in aircraft fitted with an ELT?

Do you realise how many PLB activations there are on average each day in Australia, and how many lives are saved on average each day in Australia, as a consequence of PLB activations?

Next we’ll have ATSB resuscitating its campaign to have FDRs fitted to light aircraft. “It is very difficult to know what went wrong during the flight, because the aircraft was not fitted with a flight data recording device,” an ATSB spokesperson said [dropping a not-so-gentle hint]. (They went very quiet on that campaign, post the ditching of NGA...)

None of these ELT/PLB/EPIRB devices works perfectly in all circumstances. In the circumstances in which all of them are least likely to work – or to stop working - chances are there’s no one in trouble. Everyone’s probably dead.

If you want to increase the reliability of fitted ELTs so that the bodies and the airframe can be located more quickly and therefore less expensively, you’re going to have to increase ELT system crashworthiness, lots, and that will take money, lots. However, so far as I am aware, there is no plan to change the ELT system fitted to B777s or other heavy metal, notwithstanding the many, many, many millions spent so far on trying to find MH370.

[andrewr]

The battle was hard fought, and won, on the basis of objective data, not strongly-held opinions.

I'm just interested to see the data. I didn't mean to lobby for mandatory fitment, just the middle ground between mandatory fitment and a waste of time and money.

If ELTs do sometimes save lives, talking someone out of fitting one might cost them their life. How much is a life worth? Mine is worth enough to me that I will pay the price for an ELT, on the remote chance that it might save me one day.

How many pilot/pax lives have been saved through PLB activations, which lives would not have been saved if the pilot/pax had no PLB and instead been in aircraft fitted with an ELT?

Do you realise how many PLB activations there are on average each day in Australia, and how many lives are saved on average each day in Australia, as a consequence of PLB activations?

No idea. How many aircraft crashes are there per day in Australia, and how many lives are saved due to PLBs? As I said I am interested to see the data.

[Creampuff]

You are free to fly only in aircraft to which an ELT is fitted.

You are also free to carry a PLB whenever you fly.

Do you carry a defribulator when you fly? It could save a life. And what is life worth?

Satellite phone?

At least two turbine engines?

The trouble with the 'what is a life worth' argument is that no matter what you are doing, there's almost always something more that you could be doing that might make you and your pax safer and might make your and your pax' chances of survival greater. But always at a cost. And as Dick Smith says, you only get the safety that you can afford.

That's why people still die in accidents involving aircraft built to the highest standards, crews trained and tested to the highest standards, air traffic control systems built to the highest standards and operated by air traffic controllers trained to the highest standards, in and out of airports built and equipped to the highest standards.

That's why the response to the Germanwings incident is not to make a regulation requiring that all 2 pilot aircraft have at least 3 pilots assigned for each flight, to ensure that there are always at least 2 qualified pilots on the flight deck when one of the pilots needs to visit the toilet. Someone's decided that even though it's easy to do, the consequent cost is not justified by the risk, even if it could save lives. That someone has decided what is a life is worth. That decision is actually made many times, every day.

[andrewr]

I should never have mentioned what is a life worth. My point was that mine is worth enough to me that I fit an ELT to my aircraft. Everyone is free to make their own decision on that one.

But I'm still looking for data to support the contention that my ELT is a complete waste of money.

[gerry111]

"But I'm still looking for data to support the contention that my ELT is a complete waste of money."
You are free to protect yourself and your pax by having an ELT, if you so wish. I prefer to have a PLB on my belt that I can better monitor for serviceability. And yes, I do know how to activate it.

[Creampuff]

So go forth and look, ar. Presumably you wouldn't be silly enough to make a decision until you've found and digested the data.

The answer to your implied question depends upon what you would choose to do with the money that you would otherwise spend on fitting an ELT.

If, for example, the aircraft you fly doesn't have an all-cylinder engine monitor, or it has one but you don't have a clue what it's telling you or what to do about what it's telling you, the best bang for your safety buck would be to fit an all-cylinder engine monitor, learn what it's telling you and learn what to do about what it's telling you.

If, as another example, you're prone to scud-running in bad weather, the best bang for your safety buck would be to pay a mate to tie you up each time you have an irresistable urge to go scud-running in bad weather.

Why not be safer and just fit two ELTs?

[andrewr]

I didn't mean to imply any questions or start a debate on engine monitors. My only question is the explicit one:
Where can I find this data about the (lack of) effectiveness of ELTs?

I searched, all I found was an ATSB study which found they activate in 40-60% of accidents where they would be expected to activate and save an average of 4 lives per year (I am slightly skepical)

[Creampuff]

Just fit 2 ELTs and you'll be fine.

[gerry111]

andrewr,

Why not also buy sufficient PLB's for all on board your aircraft? And give your pax a safety briefing on their operation before going flying? All wear them on belts. Modern 406 MHz PLB's are rather inexpensive and importantly have modern technology batteries. That helps to make them very reliable. By all means fit an ELT (or two!) to your aircraft. That's if you genuinely believe that to be good value for your money spent on safety.

[LeadSled]

I'm just interested to see the data. I didn't mean to lobby for mandatory fitment, just the middle ground between mandatory fitment and a waste of time and money

Andrewr,
A previous post already tells you where you can get the information that proves --- yes, proves, that fixed ELT are a waste if time and money, especially money.

Remember, the initial push for fixed ELT came from the US, but not from FAA, but from Congress, as a result of a loss (a single loss) in Alaska, and extravagant claims about fixed ELT.

Nowhere was a fixed ELT ever cost/benefit justified.

The "politics" of the fixed ELT saga in AU was somewhat different, remember, when a bad idea takes root in CASA (or its predecessors) it is very hard to kill. It became a straight head to head battle between the GA sector and CASA -- where several individuals in CASA made it very clear they didn't care how much it cost, or whether they worked of not, but they were not going to have their "authority" questioned or challenged by "the industry".

Where have we seen that more recently???

In mid-1990s, CAA/CASA came up with an unbelievable safety case, unbelievable because it was not very good fiction --- but they refused to make the data "on which they relied" public, out of "sensitivity" to the reactions of relatives of those who died.

No problem, in those days, BASI did not work hand in glove with CAA/CASA, and AOPA got all the data.

I don't remember the exact numbers now, but there were about 30+ accidents, where CAA/CASA claimed a fixed ELT would have saved lives.

On examining every one, AOPA found that six of the "aircraft" were boats, and not flying boats. Interestingly, it was a boat that made a very good case for the "portable ELT" --- the successful rescue of Tony Bullimore by the RAN in Arctic waters --- his fixed rescue beacon failed, it was his portable that was detected.

AOPA found yet another case of the good old "shifting the decimal point" trick, which showed that about 3.5% of aircraft went into the water, where ELT are 100% useless, the real figure was 35%.

In one hilarious case, a light aircraft force landed in the main street of a small Victorian country town, coming to a halt right in front of the police station. With a straight face, it was claimed that a fixed ELT would have helped to find the aircraft faster --- if the pilot remembered to turn it on before he exited an undamaged aircraft, and headed to the pub for a calming beer.

The bottom line, in some 5 or 6 cases a fixed ELT may have worked, but in each case a PLB would have also worked. The really sad cases were several which were survivable, but the fixed ELT failed, and the one or more survivors died after some days of injuries or exposure or both. One of these sad cases was, in fact, the example used by CAA/CASA in all the publicity for fixed ELT --- on detailed examination, the aircraft had been fitted with a fixed ELT, it didn't work, a portable and two young lives would have been saved.

AOPA also dug up a number of cases of airline crashes (Airbus routinely fitted fixed ELT to their products, next to the Flight Recorder and the Voice Recorder) and in not one case, even when the tail survived largely intact, in none of the cases did the fixed ELT work.

The fixed ELT failure modes are completely predictable, no useful signal is broadcast, because the aerial of aerial cable is disrupted in the crash sequence.

AOPA research with Civil Air Patrol in USA found the same results, where all aircraft had a fixed ELT --- rare was the case that a fixed ELT broadcast a signal.

As already posted, CASA did a post implementation study, as required by the legislation, about six years later, the results were the same, there was only one case were a downed aircraft transmitted a detectable signal, and that was only detected flying right over the top, after the aircraft had been found ---- as usual, the box worked, but the aerial/cable was stuffed, but if you were close enough (1000 ft overhead) a weak signal was detected.

So, the result ---- a 95% or greater failure rate in the real world.

All the AOPA research results were published in the AOPA magazines of the day, old copies can be found at the AOPA office, CASA should have archived copies of the post implementation review.

Tootle pip!!

PS1: Occasionally, something good comes out of Australia --- which played the major roll in changing the specifications for a PLB that would talk to the new satellites, most significantly changing the temperature range specified, that made a "commodity priced" PLB possible.

The original specifications never even envisaged a PLB, and required the battery to work at -70C or so --- Australia successfully argued that was not relevant to a PLB, as a human body could not survive that temperature.

Creampuff has already told you about the results, PLBs are now far more widely used tha ever, their contribution to saving of lives is immense.

PS2: I would not take ATSB figures at face value, unless I investigated each claim, particularly due to the loose definitional usage of ELT/EPIRB/PLB. There are not too many GA aircraft with a fixed ELT.

[Creampuff]

From the most recent Annual Report of the Australian Maritime Safety Authority (here: Annual Reports - Australian Maritime Safety Authority (AMSA) ):

AMSA’s principle[sic] functions are to:
• …
• rescue people in maritime and aviation distress situations
…
During 2013-14, AMSA coordinated the search and rescue of 4619 people across 7124 incidents, representing 99.59 per cent of lives saved.

I’d also commend this advice from AMSA’s website (here: Aviation search and rescue education - Australian Maritime Safety Authority (AMSA) ):

If a registered civil or ultralight aircraft crashes, ditches or goes missing, the Australian Maritime Safety Authority's (AMSA) Rescue Coordination Centre - Australia has national responsibility for coordinating the search and rescue.

The most important things to improve your chances of survival, and to help search and rescuers are:

1. Know how to handle an emergency, forced landing or ditching.

2. Before departing, submit a flight plan, SARTIME or leave a Flight note with someone responsible. If you have to make a forced landing, a major confidence booster to survival is knowing that a search will have commenced.

3. In the event of an emergency, get out a MAYDAY or PAN call. If not operating on an ATS frequency, always have the area or overlying airspace frequency set for immediate use. This is the most responsive method to alert the search and rescue system.

4. During an emergency, after completing the pilot actions and communications calls, activate your 406 MHz distress beacon (ELT, PLB or EPIRB). Make sure it is registered with AMSA.

5. Make sure you have survival equipment suitable for the area being overflown. Know how to use it, and make sure you keep it well maintained. An emergency supply of drinking water is crucial. Also ensure that you have an emergency supply of prescribed medications.

[dubbleyew eight]

andrewr loading up your aircraft with bumf to allow you to be rescued quicker is the dumbest idea I have ever heard in aviation.
what competent people do is maintain the aircraft so that it doesn't fail in the first place.

what you are actually saying in your posts is that you have no confidence in the maintenance of your aircraft.
recognise that that is the problem and attend to it.

5. Make sure you have survival equipment suitable for the area being overflown.

that is such wonderful advice from people who have no real clue.
Bill Bell actually ditched an aircraft in the pacific when a ferry flight hit higher winds than ever expected.
He found that you only had available to you the stuff that was in your pockets.
he had all the gear on board and the aircraft floated. he repeatedly dived into the aircraft and couldn't locate a single item of his emergency gear.

far better to attend to your aircraft maintenance competently (illegally if needed) and never put yourself in the situation.
W8.

[Creampuff]

that is such wonderful advice from people who have no real clue.

So how many people were rescued in rescues you coordinated in 2014, W8? Round hundreds will do.

If it's fewer than 4,600, I'm not sure you have the expertise to express an opinion that's better informed than AMSA's.

He found that you only had available to you the stuff that was in your pockets.

That's why they invented pocket sized PLBs.

Anyone who doesn't fly with a 406MHZ GPS-equipped and AMSA-registered PLB in his or her pocket is as silly as someone who assumes that a perfectly maintained piece of machinery can never fail.