PA31 hit truck at Barwon
The report may not be the issue, but the report should be the source of information that can be used for learning. But the quality of the report is so poor as to be laughable.
The author could not even figure out that the ATSB's sister department publishes Australian Design Rules which specifies the maximum height of vehicles as 4.3m not 4,6m as published in the report. When you can get basic details like that right, how can you believe anything else? It completely destroys the reports credibility.
Nor did the report figure out or comment that there are no airport warning signs on the road. Which means not only did the ATSB not visit the site, they did not even look at Google Earth.
The report did not calculate the approach gradient that the Chieftan followed based on the truck height. It used either the fallacious 4.6m figure or a 5% (3 degree) gradient.
The actual truck height (3.95m) at a distance of 78m to the threshold (from the report) is 2.9 degrees. Low, but not quite dragging it in on the props.
The Cheiftan was low - but which of us wants to cast a stone? But the truck driver (reportedly) neither saw or felt the aircraft. I would have liked to see a discussion about what role the driver has in being aware of aircraft on final and exercising some judgement and whether it might have made a difference if the road was correctly signed. .
The author could not even figure out that the ATSB's sister department publishes Australian Design Rules which specifies the maximum height of vehicles as 4.3m not 4,6m as published in the report. When you can get basic details like that right, how can you believe anything else? It completely destroys the reports credibility.
Nor did the report figure out or comment that there are no airport warning signs on the road. Which means not only did the ATSB not visit the site, they did not even look at Google Earth.
The report did not calculate the approach gradient that the Chieftan followed based on the truck height. It used either the fallacious 4.6m figure or a 5% (3 degree) gradient.
The actual truck height (3.95m) at a distance of 78m to the threshold (from the report) is 2.9 degrees. Low, but not quite dragging it in on the props.
The Cheiftan was low - but which of us wants to cast a stone? But the truck driver (reportedly) neither saw or felt the aircraft. I would have liked to see a discussion about what role the driver has in being aware of aircraft on final and exercising some judgement and whether it might have made a difference if the road was correctly signed. .
The author could not even figure out that the ATSB's sister department publishes Australian Design Rules which specifies the maximum height of vehicles as 4.3m not 4,6m as published in the report. When you can get basic details like that right, how can you believe anything else? It completely destroys the reports credibility.
The Cheiftan was low - but which of us wants to cast a stone?
The pilot looked down momentarily at the throttle quadrant as they put their hand on the throttle control.
look left
check my reply to you on the other post. 4.3m is the maximum. Vehicle dimensions are defined by ADR 43/04 which is managed by a department of DIRD which I believe is in the same building as the ATSB.
As it happens, I'm on the phone to the head of vehicle standards at Vicroads on another matter, but he has confirmed 4.3m is the height limit unless the vehicle has an exemption, where there are restrictions on the roads that can be driven on.
4.6m is the recommended clearance for roads, which is a very different thing.
check my reply to you on the other post. 4.3m is the maximum. Vehicle dimensions are defined by ADR 43/04 which is managed by a department of DIRD which I believe is in the same building as the ATSB.
As it happens, I'm on the phone to the head of vehicle standards at Vicroads on another matter, but he has confirmed 4.3m is the height limit unless the vehicle has an exemption, where there are restrictions on the roads that can be driven on.
4.6m is the recommended clearance for roads, which is a very different thing.
My issue is that the report can't get the facts right. It said the max height of vehicles is 4.6m and referenced a Vicroads document on recommended road clearances, not a vehicle requirement document.
The emphasis is on recommended. There are plenty of bridges and other obstructions below this.
ADR 43/04 specifies vehicle dimensions. The max height is 4.3m.
State authorities allow exemptions under some circumstances. These will require an approval beyond homologation. In Victoria the common exemption is 2 level cattle trucks that will be permitted up to 4.6 m. But these are only allowed on declared roads and may include other restrictions. Other states have other exemptions. WA has numerous ones to cater for mining vehicles.
My favorite exemption is for Bushmaster vehicles that exceed the maximum single axle load limit. They need individual exemption each and every time they are driven on public roads that is valid only for the specified route and time.
The salient point is that:
a) The ATSB incorrectly refers to a non controlled vicroads advisory document as a defining document. The correct reference is ADR 43/04. Its not hard to get right.
b) the ATSB incorrectly list the maximum vehicle height as 4.6m. There is no requirement to provide 4.6m clearance. Its a recommendation. There would be a bridge reconstruction project that would rival the level crossing project if it was a requirement.
c) The ATSB has criticized the pilot for being too low (which he was by admission) but failed to note that at the point of impact the aircraft was only 260mm below a 3 deg approach angle.
d) The ATSB did not consider if the Chieftan was on a 3 deg approach if it would have still hit the vehicle.
e) The ATSB did not comment on whether the driver had any degree of responsibility in having enough situational awareness to see an aircraft on his right hand side approaching at basically the same height.
f) The ATSB did not comment on the lack of warning road signs and whether or not this may be a useful risk mitigation strategy.
I agree that some of the pilots explanation is flaky. But notice they are not quotes, but the ATSB's summary points. The pilots comments may have been taken out of context or paraphrased by the ATSB. If the ATSB can change transcripts of recorded radio transmissions, then they can misrepresent a pilots interview responses.
I also agree that an approach that low is not good practice. But we're not all perfect and there should be some tolerance for deviation.
The emphasis is on recommended. There are plenty of bridges and other obstructions below this.
ADR 43/04 specifies vehicle dimensions. The max height is 4.3m.
State authorities allow exemptions under some circumstances. These will require an approval beyond homologation. In Victoria the common exemption is 2 level cattle trucks that will be permitted up to 4.6 m. But these are only allowed on declared roads and may include other restrictions. Other states have other exemptions. WA has numerous ones to cater for mining vehicles.
My favorite exemption is for Bushmaster vehicles that exceed the maximum single axle load limit. They need individual exemption each and every time they are driven on public roads that is valid only for the specified route and time.
The salient point is that:
a) The ATSB incorrectly refers to a non controlled vicroads advisory document as a defining document. The correct reference is ADR 43/04. Its not hard to get right.
b) the ATSB incorrectly list the maximum vehicle height as 4.6m. There is no requirement to provide 4.6m clearance. Its a recommendation. There would be a bridge reconstruction project that would rival the level crossing project if it was a requirement.
c) The ATSB has criticized the pilot for being too low (which he was by admission) but failed to note that at the point of impact the aircraft was only 260mm below a 3 deg approach angle.
d) The ATSB did not consider if the Chieftan was on a 3 deg approach if it would have still hit the vehicle.
e) The ATSB did not comment on whether the driver had any degree of responsibility in having enough situational awareness to see an aircraft on his right hand side approaching at basically the same height.
f) The ATSB did not comment on the lack of warning road signs and whether or not this may be a useful risk mitigation strategy.
I agree that some of the pilots explanation is flaky. But notice they are not quotes, but the ATSB's summary points. The pilots comments may have been taken out of context or paraphrased by the ATSB. If the ATSB can change transcripts of recorded radio transmissions, then they can misrepresent a pilots interview responses.
I also agree that an approach that low is not good practice. But we're not all perfect and there should be some tolerance for deviation.
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'Didnt want to get the turbos hot'
'Windsheer'
What a joke of a report.
'Windsheer'
What a joke of a report.
In addition to flying duties, the pilot was also working as the company maintenance controller, and had recently taken on extra administrative duties. They stated that they were distracted during the incident flight by these additional pressures.
If the pilots mind was so consumed by his job as a maintenance controller and recent extra administrative duties that he felt all this was affecting his flying judgment which is why he pranged his aircraft, you have to question his decision to fly that day. Mind you he needed to dredge up a quick excuse to ATSB and that was a good as any I suppose.
When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
Sounds like a potentially dangerous gimmick retracting flaps when very low on final rather than apply power and reheat the turbochargers. By ATSB accepting the pilot's excuses and not offering expert engineering comment to refute the pilot's reasoning, how can other pilots reading this report expect to learn from this incident.
The ATSB did not comment on whether the driver had any degree of responsibility in having enough situational awareness to see an aircraft on his right hand side approaching at basically the same height
I would have liked to see a discussion about what role the driver has in being aware of aircraft on final and exercising some judgement
Or was this TIC/sarcasm/windup and I missed it?
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Sounds like a potentially dangerous gimmick retracting flaps when very low on final rather than apply power and reheat the turbochargers. By ATSB accepting the pilot's excuses and not offering expert engineering comment to refute the pilot's reasoning, how can other pilots reading this report expect to learn from this incident.
This example shows that, not only is the poor writing failing to effectively convey safety lessons, but that messages that are outright wrong are being conveyed.
Here is the exact wording from the report:
When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
Written this way, it sounds like the ATSB speaking. There is thus considerable implied authority to those words. A young pilot, transitioning to a turbocharged type, for example, may take away messages about turbocharger cooling and the validity of retracting flaps on final for this purpose.
But we know that these words were probably those of the pilot, which dramatically changes their authority. The report should have been written such that it was clear that those words were from the pilot.
How about, "Upon realising the aircraft was low on the approach, the pilot elected to retract one stage of flap, rather than apply power. The pilot believed that applying power would adversely impact on turbocharger cooling".
Presenting the pilot's words in that "Pilot comments" section was a terrible idea and has had a lot to do with the misinterpretations that can follow. There is no good reason to present the comments from the various parties that way. As we have seen, it can result in a dramatic misrepresentation of the authority of the words.
Well said and well explained, FGD135.
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Correct
I'd love to know where retracting flaps in order to flatten glidepath on final has come from, rather than use power.
Yes the engine is turbocharged. Without going to deep into the weeds here: roughly speaking the TIT at say 18" MP on final might be around 1200-1300dF (it's been a while since I've flown one). On a correctly set up J2B, the TIT at full power should be: between 1200-1300dF!
'Saving turbos'! How?
I've been made aware of this novel approach to approaches in PA31s before. It's flawed in many directions, and based on myth and OWTs. This pilot should have known better.
I'd love to know where retracting flaps in order to flatten glidepath on final has come from, rather than use power.
Yes the engine is turbocharged. Without going to deep into the weeds here: roughly speaking the TIT at say 18" MP on final might be around 1200-1300dF (it's been a while since I've flown one). On a correctly set up J2B, the TIT at full power should be: between 1200-1300dF!
'Saving turbos'! How?
I've been made aware of this novel approach to approaches in PA31s before. It's flawed in many directions, and based on myth and OWTs. This pilot should have known better.
Last edited by Lumps; 7th Sep 2017 at 05:29.
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FGD135 - Any chance you could apply for a job with the ATSB as a consultant to correct their reports at the draft stage..?! Your example really highlights how poorly the ATSB version is written. Keep up the good work! 
In a feverish desire not to blame anyone the ATSB reports now have little learning value. Contrast the NTSB which is not afraid to attribute a probable cause. See similar incident below.
https://www.youtube.com/watch?v=3dfjRKPBWw8
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The student pilot's failure to maintain clearance from obstacles on the runway approach path.
Contributing to the accident was the airport management's decision to relocate the runway
displaced threshold, which did not provide an adequate safety margin for approaching aircraft,
and the automobile driver's inadequate lookout for approaching aircraft before crossing the
runway's approach path.
Page 2 of 6 CEN13LA041
Findings
Aircraft Descent/approach/glide path - Not attained/maintained (Cause)
Personnel issues Incorrect action performance - Student pilot (Cause)
Environmental issues Ground vehicle - Effect on operation (Factor)
Airport facilities/design - Effect on operation (Factor)
https://www.youtube.com/watch?v=3dfjRKPBWw8
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The student pilot's failure to maintain clearance from obstacles on the runway approach path.
Contributing to the accident was the airport management's decision to relocate the runway
displaced threshold, which did not provide an adequate safety margin for approaching aircraft,
and the automobile driver's inadequate lookout for approaching aircraft before crossing the
runway's approach path.
Page 2 of 6 CEN13LA041
Findings
Aircraft Descent/approach/glide path - Not attained/maintained (Cause)
Personnel issues Incorrect action performance - Student pilot (Cause)
Environmental issues Ground vehicle - Effect on operation (Factor)
Airport facilities/design - Effect on operation (Factor)
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Yes the engine is turbocharged. Without going to deep into the weeds here: roughly speaking the TIT at say 18" MP on final might be around 1200-1300dF (it's been a while since I've flown one). On a correctly set up J2B, the TIT at full power should be: between 1200-1300dF!
MAP remained unaltered, and was not reduced until short final.
The above quoted from my copy of the Chieftain PIM.
Here we go again!!! 
One of the many complaints leveled at the ATSB is the timeliness of their investigations. If FGD was in the ATSB wordsmithing his reports there would be no output.
I'm not sure whether he is deliberately being misleading or only gives the reports a superficial glance.
They were noted in the report as being comments from the pilot.If you are going to use quotes from the report then use the context of the quote. This is the quote in its context and who the comment is attributed to:
I have put in the bold part. So the report does actually attribute the comment in the way you suggest that it should! Maybe you should actually read the report and not approach it like a harrumphing school principal with a big red pen.
This is from the findings section which is the ATSB voice:
So the ATSB is in fact saying that the technique used by the pilot didn't work in reducing the rate of descent. If a young pilot interprets the findings in the way you have suggested then I don't really think that its the ATSB's report writing that is at fault.
Your rewrite is actually very similar to what was written:
Your statement:
The ATSB version:
On TMs point:
Are you talking performance, aeronautical or mechanical? Other pilots can learn from this incident by not reducing flap on final to reduce their RoD and use power when its needed otherwise you may hit something on approach. You don't need expert opinion to draw that conclusion.
I'm not sure whether he is deliberately being misleading or only gives the reports a superficial glance.
Here is the exact wording from the report:
When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
Written this way, it sounds like the ATSB speaking. There is thus considerable implied authority to those words. A young pilot, transitioning to a turbocharged type, for example, may take away messages about turbocharger cooling and the validity of retracting flaps on final for this purpose.
But we know that these words were probably those of the pilot, which dramatically changes their authority. The report should have been written such that it was clear that those words were from the pilot.
When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
Written this way, it sounds like the ATSB speaking. There is thus considerable implied authority to those words. A young pilot, transitioning to a turbocharged type, for example, may take away messages about turbocharger cooling and the validity of retracting flaps on final for this purpose.
But we know that these words were probably those of the pilot, which dramatically changes their authority. The report should have been written such that it was clear that those words were from the pilot.
Pilot comments
The pilot of VH-JQS provided the following comments:
• They had flown into Barwon Heads regularly over the previous five to six years and were familiar with the airport, including the displaced threshold and the vicinity of the Barwon Heads Road.
• In addition to flying duties, the pilot was also working as the company maintenance controller, and had recently taken on extra administrative duties. They stated that they were distracted during the incident flight by these additional pressures.
• The desired approach profile was about a 3° (5 %) descent profile. The pilot was aiming to land about a quarter of the way into the runway in order to ensure clearance over Barwon Heads Road.
• There were no issues with visibility or cloud cover but there was a gusting wind from the northwest. The aircraft became low on approach due to turbulence and windshear.
• When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
• The truck was not detected earlier as it had been obscured by a row of trees to the south-west of the airport.
The pilot of VH-JQS provided the following comments:
• They had flown into Barwon Heads regularly over the previous five to six years and were familiar with the airport, including the displaced threshold and the vicinity of the Barwon Heads Road.
• In addition to flying duties, the pilot was also working as the company maintenance controller, and had recently taken on extra administrative duties. They stated that they were distracted during the incident flight by these additional pressures.
• The desired approach profile was about a 3° (5 %) descent profile. The pilot was aiming to land about a quarter of the way into the runway in order to ensure clearance over Barwon Heads Road.
• There were no issues with visibility or cloud cover but there was a gusting wind from the northwest. The aircraft became low on approach due to turbulence and windshear.
• When they realised they were becoming low on the approach the pilot reduced flaps by 10° rather than apply power. This was done to avoid reheating the turbo chargers as they had already cooled.
• The truck was not detected earlier as it had been obscured by a row of trees to the south-west of the airport.
This is from the findings section which is the ATSB voice:
Findings
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
• The aircraft descended below the desired approach profile and the corrective action was not effective in sufficiently reducing the rate of descent.
These findings should not be read as apportioning blame or liability to any particular organisation or individual.
• The aircraft descended below the desired approach profile and the corrective action was not effective in sufficiently reducing the rate of descent.
Your rewrite is actually very similar to what was written:
Your statement:
How about, "Upon realising the aircraft was low on the approach, the pilot elected to retract one stage of flap, rather than apply power. The pilot believed that applying power would adversely impact on turbocharger cooling".
Safety analysis
At about half a nautical mile from the runway, the aircraft became low on the approach. When the pilot recognised that the aircraft was too low, they elected to reduce the flap setting by 10° rather than add power. As the aircraft got closer to the runway, the aircraft was still lower than the
desired approach profile, at which point the pilot elected to add power to gain height. Despite this action, the aircraft remained below the desired approach profile until it made contact with the truck.
At about half a nautical mile from the runway, the aircraft became low on the approach. When the pilot recognised that the aircraft was too low, they elected to reduce the flap setting by 10° rather than add power. As the aircraft got closer to the runway, the aircraft was still lower than the
desired approach profile, at which point the pilot elected to add power to gain height. Despite this action, the aircraft remained below the desired approach profile until it made contact with the truck.
On TMs point:
By ATSB accepting the pilot's excuses and not offering expert engineering comment to refute the pilot's reasoning, how can other pilots reading this report expect to learn from this incident.
Originally Posted by Lead Balloon
Use attitude to adjust airspeed. Use power to adjust rate of descent.