Report of plane missing near Renmark SA

[VH-MLE]

One of the training issues to me is that retarding a power lever to flight idle instead of zero thrust seems to be an ongoing problem in these classes of aircraft & the cause of many loss of control accidents in training. From memory VMCA in the C441 was around 91 or 95 KIAS, with VYSE of 120KIAS, but I can distinctly recall our C&T pilot demonstrating that maintaining control was extremely difficult even at 120KIAS with a power lever fully retarded instead of at zero thrust.

This message does not seem to be getting through & in the absence of Australian based simulators for many of these aircraft, a stronger focus is required by CASA/ATSB etc...

I did not know the front seat crew members, however SG was a great guy & a very professional operator...

[Horatio Leafblower]

VH-MLE you are spot on.
ATSB blaming the operator's ops manual is bull****: For the purposes of the operation, CASA was the operator AND they had accepted those procedures in Rossair's manual.

SG should never have been in that seat and should never have put himself, or those pilots, in that situation. He was the pilot in command.

We have been doing Conquest endorsements in Australia since the first airframes were imported (ironically, by Rossair I think) in the 1970s. This is the first fatality. It speaks to the dwindling experience and judgement available in CASA, and the dwindling experience and judgement available in General Aviation at that time in particular, but across the last 20 years generally.

I have been doing Conquest endorsements for 6 years now and piston twin endorsements for 5 years before that. I am fortunate to have had Flying Bear as a resource and a mentor as I have learnt to teach Turboprop handling; but as a Chief Pilot and CFI most of my learning has been by trial and error. Some days I wonder if my survival to this point has been pure good luck.

CASA lacks the expertise, currency and testicular fortitude to provide industry development, preferring to pass the buck. It's time to ask Ben Cook, Tony Kern and other respected training leaders to lead a program to build industry capability.

[Hoosten]

And the report is spot on time, 3 years, awesome work!

[Centaurus]

most of my learning has been by trial and error. Some days I wonder if my survival to this point has been pure good luck.

Know the feeling. I was being checked out on the Cessna 425 Conquest. On the downwind leg of a left circuit, the chief pilot acting as instructor and at least 1000 hours as pilot in command on type, pulled back the throttle on the left engine against the idle stop. That is not zero thrust. Although initially flying at a safe speed I was unpleasantly surprised at the immediate speed decay and worse still my inability to counter the drag of the fully closed throttle setting.

Turning final towards the windmilling engine I doubted if I had the leg strength to maintain directional control. I remember telling the instructor there was no way I could maintain directional control if he asked for a single engine go around. He said nothing.

It was a struggle to stop it rolling into the dead engine. It was poor airmanship by the instructor and certainly endangered the flight. I didn't mind the simulated engine failure but his failure to set zero thrust as soon as I had identified the dead engine left no margin for mishandling. Frankly it rattled me and I had lots of hours on turbo-props.

It is a pity that ATSB do not adopt the FAA policy of publishing a most probable cause of an accident when there is insufficient evidence to produce an irrefutable cause. At the moment it becomes anyone's guess as we can see by Pprune comments and nothing is learned especially after three years. .

[Hoosten]

That scenario Centaurus is frightening. The fact that all of us following (instructing on these types) are relying on our mentors having to figure it out through trial and error in this country is also frightening.

[VH-MLE]

Unfortunately, that's GA in this country & no doubt most others that have a GA wing (pardon the pun...) in their country.

Also unfortunately, if you have a bad mentor - which may not be easy to identify whilst you're trying to learn/gain some experience/knowledge/judgement/wisdom, you are certainly set up for trouble with a capital "T".

Not saying there was a bad mentor in this tragic case as I don't have any knowledge of those involved in the front two seats or who their mentors might have been... Personally, I have always felt that the bulk of GA pilots receive far too little supervision/training for their roles...

Just my 2 lire worth...

[Lead Balloon]

Someone brought my attention to this in the ATSB Report. (I had to read this twice to make sure I wasn’t hallucinating):

The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

So is that because the ATSB is gutless, weak, incompetent or just plain old corrupt?

Section 32 of the TSI Act says:

32 ATSB may require persons to attend and answer questions etc.

(1) Where the ATSB considers it necessary to do so for the purposes of an investigation, the ATSB may:

(a) require a person to attend before the ATSB and answer questions put by any person relating to matters relevant to the investigation; or

(b) require a person to produce specified evidential material to the ATSB.

(2) Subsection (1) does not apply in relation to a person in his or her capacity as a coroner.

(3) The requirement under subsection (1) must be by a notice in writing. The notice must be signed by the Chief Commissioner and must specify the time and place at which the person is required to attend before the ATSB or produce the evidential material specified in the notice. That time must be reasonable having regard to the circumstances.

(4) When a person attends before the ATSB under paragraph (1)(a), the ATSB may require the questions to be answered on oath or affirmation. For that purpose, the ATSB may:

(a) require the person to take an oath or make an affirmation that the answers the person will give to the questions will be true; and

(b) administer an oath or affirmation to the person.

(5) A person to whom a requirement is given in accordance with this section must not:

(a) fail to attend before the ATSB in accordance with the requirement; or

(b) refuse to take an oath or make an affirmation when required by the ATSB to do so; or

(c) refuse or fail to answer a question lawfully put to the person; or

(d) fail to produce to the ATSB the specified evidential material in accordance with the requirement.

Penalty: 30 penalty units.

Note: Self‑incrimination is not an excuse for failing to answer a question. See section 47.

(6) Strict liability applies to the element of the offence against subsection (5) that the requirement is given in accordance with this section.

(7) A person who attends before the ATSB in accordance with a requirement under paragraph (1)(a) or (b) is entitled to be paid, in relation to that attendance, fees and allowances for expenses fixed by, or calculated in accordance with, the regulations.

What is that power for, if not to compel the provision of information and the answering of questions for the purposes of an investigation? You don’t “request”, you “require”. And you then prosecute those who fail to comply with the requirement to produce material and answer questions.

The ATSB was “unable” to make a determination about the circumstances under which the incorrect procedure was approved for use by the operator, because the ATSB failed to exercise powers that it has to obtain information about those circumstances.

There will some sophistry around words like “approval” and “acceptance” - a matter touched on in the report - but the bottom line is that the incorrect procedure got there ‘somehow’ and there should be records in CASA and knowledge in CASA about that ‘how’.

Astonishing.

[KRviator]

Originally Posted by Centaurus

Know the feeling. I was being checked out on the Cessna 425 Conquest. On the downwind leg of a left circuit, the chief pilot acting as instructor and at least 1000 hours as pilot in command on type, pulled back the throttle on the left engine against the idle stop. That is not zero thrust. Although initially flying at a safe speed I was unpleasantly surprised at the immediate speed decay and worse still my inability to counter the drag of the fully closed throttle setting.

Turning final towards the windmilling engine I doubted if I had the leg strength to maintain directional control. I remember telling the instructor there was no way I could maintain directional control if he asked for a single engine go around. He said nothing.

It was a struggle to stop it rolling into the dead engine. It was poor airmanship by the instructor and certainly endangered the flight. I didn't mind the simulated engine failure but his failure to set zero thrust as soon as I had identified the dead engine left no margin for mishandling. Frankly it rattled me and I had lots of hours on turbo-props.

It is a pity that ATSB do not adopt the FAA policy of publishing a most probable cause of an accident when there is insufficient evidence to produce an irrefutable cause. At the moment it becomes anyone's guess as we can see by Pprune comments and nothing is learned especially after three years. .

It's happened before, on many different types. People do not want to learn. Here's another example this time, from a Beech 1900. Power back to flight idle, not zero thrust and they couldn't maintain control... Wash, rinse, repeat...

And what do you notice in the linked report?

Originally Posted by BASI

Since 1992, it was the practice of the operator’s check pilots to simulate one-engine inoperative by retarding the power lever of the ‘failed’ engine to ‘FLIGHT IDLE’. That was contrary to the procedure prescribed in the Federal Aviation Authority-approved Beech 1900D Airplane Flight Manual, and also to that specified in the operator’s Civil Aviation Safety Authority-approved Training and Checking Manual. Reducing power to ‘FLIGHT IDLE’ also had the effect of simulating a simultaneous failure of the engine and its propeller auto-feather system. The simulation of simultaneous inflight failures was contrary to the provisions of the CASA-approved Training and Checking Manual. During each of the simulated one-engine inoperative sequences, control of the aircraft was not regained until the power on the ‘failed’ engine was advanced to the manufacturer’s prescribed one-engine inoperative thrust power setting

So for 8 years they had been intentionally violating their C&T manual and each time, lost control until they set Zero Thrust.

[Horatio Leafblower]

It's happened before, on many different types. People do not want to learn.

I'd suggest people DO want to learn but often do not know what they do not know. Private Equity owners and champion Equestrians don't know what they are doing with flight training and don't want to invest the money when they just see another pilot that will "rip us off and leave as soon as the airlines call" or words to that effect.
The industry needs to develop a training program to build our capacity. It needs to bear the "authority" of CASA or ATSB; it needs to be credible and non-partisan.

Some in Government say to me it's up to Industry and "the Market" to sort this out but in our little corner of the world there are too many petty jealousies and historical rivalries for that to work.

CASA needs to provide leadership while there are still some in that organisation who know what that looks like.

[j3pipercub]

I think one of the reasons history seems to repeat itself constantly is culture. Bear with me. Individuals who become Checkers/Examiners in small time GA fall into 2 camps.

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA. They have seen their contemporaries go onto bigger and better things, they become resentful of the industry. As a result, this type of individual puts little effort into self improvement, as it isn’t their fault, it’s ‘the industry’. The flipside of this is these individuals are seen as a fantastic option to some operators as ‘they aren’t going anywhere’. So what you end up seeing is all the dregs floating to the top. These individuals often have little desire to teach, mentor or pass on knowledge to the next, younger generation of pilots. We have probably all met this type of individual and probably have fairly vivid memories of the meeting.

How do we cultivate a better culture and encourage a better sort of individual to stay in GA? I don’t know, just my ramblings from my limited experience. Better pay in GA maybe? No idea.

j3

Please note, this is in no way, shape, or form a comment on the Rossair accident or the individuals involved.

[Horatio Leafblower]

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA.

Sadly, largely, very true. The problem is that the ambitious people who want to make things happen (for themselves and others) actually DO make things happen, and move on.

I do wonder if the competent GA pilots that I have known would want to keep flying GA charter and instructing for $150k if they could chance their hand in the next biggest aircraft and continue to challenge their skills instead.

[Clare Prop]

Originally Posted by j3pipercub

I think one of the reasons history seems to repeat itself constantly is culture. Bear with me. Individuals who become Checkers/Examiners in small time GA fall into 2 camps.

The first and very very small camp are the amazing mentors, the ones who truly have a passion for GA. The ones who have a tireless ability and attitude to train, guide and encourage employees and students. The sort of pilots and people you want to emulate in every aspect of airmanship, ability and attitude. In my 20 years of flying, I have met 2 such people.

The second camp are the dregs. The ones due to poor ability or attitude couldn’t make it any further and are essentially ‘stuck’ in GA. They have seen their contemporaries go onto bigger and better things, they become resentful of the industry. As a result, this type of individual puts little effort into self improvement, as it isn’t their fault, it’s ‘the industry’. The flipside of this is these individuals are seen as a fantastic option to some operators as ‘they aren’t going anywhere’. So what you end up seeing is all the dregs floating to the top. These individuals often have little desire to teach, mentor or pass on knowledge to the next, younger generation of pilots. We have probably all met this type of individual and probably have fairly vivid memories of the meeting.
.

Not all of us want the lifestyle that goes with airlines, that doesn't make us "dregs".

A number of real dregs end up at CASA; their appalling attitudes, immaturity and personal vendettas that made them unemployable in GA are then used to fuel their power trips. As someone who was "strongly encouraged" to apply for a job as an FOI and looked at the money and the people I would have been working with (been in the industry long enough to have watched their career paths, some who were still in primary school when I became a CFI) I declined, I prefer to potter around in my little four seaters and make a modest but satisfying living than share office space with (and being tarred with the same brush as) those same dregs.

[Super Cecil]

Originally Posted by Horatio Leafblower

Sadly, largely, very true. The problem is that the ambitious people who want to make things happen (for themselves and others) actually DO make things happen, and move on.

I do wonder if the competent GA pilots that I have known would want to keep flying GA charter and instructing for $150k if they could chance their hand in the next biggest aircraft and continue to challenge their skills instead.

Instructing for 150K? Surely you jest?

[j3pipercub]

Clare,

Sent you a PM, I am not suggesting anyone that stays in GA is a dreg, that would be rather self depricating.

I agree with your comment regarding FOIs.

j3

[Hoosten]

Instructing for 150K? Surely you jest?

Prior to this mess there were quite a few G1's on 1 fiddy. Probably still are considering Flight Training is continuing. Although I reckon these salaries will be realigned quick smart.

[thorn bird]

But, But ,But, CAsA are the experts! aren't they?

How many CAsA FOI generated GA-isms float from Ops Manual to Ops manual around the industry?

GA-isms being a departure from widely accepted industry procedures or more specifically Flight Manual
or Pilot operating handbook manufacturers recommended procedures on the basis of CAsA expert opinions.

I've seen a few doozies at times.

[Hoosten]

The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.

A morally bankrupt organisation.

So is that because the ATSB is gutless, weak, incompetent or just plain old corrupt?

All of that, and confirmed by their actions.

[VH-MLE]

Unfortunately, the ATSB are no longer at arm's length from CASA.

It wasn't that long ago that the ATSB had no qualms identifying any perceived failings when investigating an accident - including CASA failings. It used to be that they'd look at all the holes in the Swiss cheese, however as of at least the Pelair accident at Norfolk Island, they only really looked at the last piece of cheese i.e. the pilot in that accident and as a result, ATSB credibility has been shot to pieces. To my mind, this is due to the personalities & (cosy?) relationships that exist at high levels within CASA/ATSB/Government...

As stated above, the fact that CASA didn't supply requested/required information as part of an investigation & that this apparently was not pursued appropriately,only reinforces this viewpoint...

[Duck Pilot]

Part of the problem is that the CASA FCAT program inhibits FOI’s from remaining current enough to be safe, let alone being able to be in an operational seat to do any kind of assessment on a pilot or crew, particularly if any kind of simulated abnormals are required.

I know of an FOI who once tried to take off with the pitot cover on in a Twin Comanche whilst doing re-currency training, I thought something was wrong when the airspeed indicator started going backwards at about 40 knots!!!!

Part of the reason why I no longer work for CASA, I wasn’t sacked I was simply frustrated that I wasn’t given adequate opportunity to keep my fundamental cognitive skills proficient enough to the level that I expected of myself as a professional pilot. I know that a very large majority of current and past CASA FOIs will agree 100% with regards to this statement.

This accident should never of happened, CASA’s processes failed Steve and both of the two pilots who were tragically killed in this accident. The processes should never have allowed this training environment to occur. I bet nothing has changed and the same sh!t is still happening today.

CASA must let the current FE’s and Instructors do the potentially dangerous stuff, if it’s absolutely required. To many of these unnecessary training accidents have occurred over the years.

[Old Akro]

Part of the problem is that the CASA FCAT program inhibits FOI’s from remaining current enough to be safe

One wonders what the FOI was doing there? Ballast? The stuff about not being able to communicate and needing to tap the check pilot just doesnt pass the smell test.

And if they briefed beforehand on the tap signalling system, then surely the flight programme was discussed and the engine out procediure was part of the flight that was discussed with and approved by the FOI.