ATSB clearly holds back Mt Hotham incident report
Pretty good write up, shows the benefits of keeping good raw data and hand flying skills current.
Join Date: Apr 2008
Location: Australia
Posts: 490
Likes: 0
Received 0 Likes
on
0 Posts
What a debacle.
Any truth to the rumor that the report was delayed due to disagreements about whether there should be more discussion on the airspace category?
Self separating 5 aircraft inbound by radio is difficult in VMC. In IMC it would be extremely difficult - separation becomes more luck than good management.
This is exactly the situation Class E airspace is designed to avoid. Instead of 5 pilots with 5 plans developed on the fly for how they will maintain separation, you have ATC with well planned and designed procedures. This relieves pilots of the separation workload, allowing them to concentrate on the actual approach. The report touches on workload, without any real discussion on why the workload is so high.
Without Class E Australia is basically relying on low traffic densities to ensure that you don't get multiple IFR aircraft trying to do the same thing at the same time. Every so often, that doesn't work out. According to the report CASA calculated the collision risk as 1 in 7200 years - I would be interested to see the assumptions behind that.
Any truth to the rumor that the report was delayed due to disagreements about whether there should be more discussion on the airspace category?
Self separating 5 aircraft inbound by radio is difficult in VMC. In IMC it would be extremely difficult - separation becomes more luck than good management.
This is exactly the situation Class E airspace is designed to avoid. Instead of 5 pilots with 5 plans developed on the fly for how they will maintain separation, you have ATC with well planned and designed procedures. This relieves pilots of the separation workload, allowing them to concentrate on the actual approach. The report touches on workload, without any real discussion on why the workload is so high.
Without Class E Australia is basically relying on low traffic densities to ensure that you don't get multiple IFR aircraft trying to do the same thing at the same time. Every so often, that doesn't work out. According to the report CASA calculated the collision risk as 1 in 7200 years - I would be interested to see the assumptions behind that.
In IMC it would be extremely difficult - separation becomes more luck than good management.
Without Class E Australia is basically relying on low traffic densities to ensure that you don't get multiple IFR aircraft trying to do the same thing at the same time. Every so often, that doesn't work out. According to the report CASA calculated the collision risk as 1 in 7200 years - I would be interested to see the assumptions behind that.
So can someone correct me where I go wrong as I’m not familiar with the incident;
This incident happened nearly three years ago and the report has just been released. In the report it states that the pilot underwent testing by an FOI and was found to need remedial training.
In the interim, the same pilot has crashed departing Essendon and the investigation into that is ongoing?
Is that what has happened?
This incident happened nearly three years ago and the report has just been released. In the report it states that the pilot underwent testing by an FOI and was found to need remedial training.
In the interim, the same pilot has crashed departing Essendon and the investigation into that is ongoing?
Is that what has happened?
I don't know how reading that report you can objectively single it down purely to airspace... While I'm sure controlled airspace would have been a significant help, not following the missed approach tracking and just generally maboing flight below lower safe in IMC is never going to end well. All the other aircraft managed fine.
It's weird to me that there seems to be a chorus on Pprune of not having overly expensive regulations on safety if it's not worth the perceived cost to operators (aircraft owners), but the same matrix doesn't apply to controlled airspace.
It's weird to me that there seems to be a chorus on Pprune of not having overly expensive regulations on safety if it's not worth the perceived cost to operators (aircraft owners), but the same matrix doesn't apply to controlled airspace.
Framer - my understanding of the situation would suggest that you have hit the nail on the head (perfectly).
That encompasses a lot of geography and traffic in G & E and aerodromes, so what with the display scale and other traffic it would be pretty hard to closely monitor instrument approaches and movements in the vicinity of individual aerodromes along with everything else going on.
Well I’ll be..... If I had written this report I would want it to be written a certain way as there may well be interest from the USA considering the victims of the Essendon crash were from there. I would also be hoping that the remedial training and re-testing that was required was well documented. Maybe that could explain the delay?
In the report it states that the pilot underwent testing by an FOI and was found to need remedial training.
In the interim, the same pilot has crashed departing Essendon and the investigation into that is ongoing?
In the interim, the same pilot has crashed departing Essendon and the investigation into that is ongoing?
The report into the MtHotham incident has the looks to me like it has been sanitised to make things simpler when the Essendon report is released. The Essendon report has either just been released to the DIP's or is on the eve of being released, so, effectively this report has been staged with the Essendon report.
This report, does, however, tie itself in knots trying to avoid blaming AsA or the airspace structure. Initially, (as I recall) AsA said there was no radar coverage in the area, now its saying there was, except for a critical 6 minute period. But, the really interesting thing that I would have liked examined is why AsA can't track aircraft at Hotham, but the free web based Flighaware and Flightradar can.
Another factor that has been overlooked is the lack of met data available at MtHotham. The BOM (largely based on AsA input) dropped the TAF service at Mt Hotham. Proper weather briefing at Mt Hotham may have completely changed the decisions made by the subject aircraft.
The pilot, after the incident, reported that the GPS was not functioning correctly and the report effectively confirms this, however, this report has made no investigation of the GPS equipment, nor the autopilot, nor the GPS /autopilot coupling. There is nothing in the report that challenges or disproves the hypothesis that improper operation of the GPS and / or autopilot contributed. Nor does the report give a robust investigation of RAIM. It makes the assertion that RAIM was available largely because other aircraft did not report difficulty. But given the critical role RAIM plays, and the brevity of typical RAIM outages, this report is deficient in its analysis of RAIM.
Finally, the lack of radar surveillance, meteorological information and air traffic control for such a busy airport with large charter aircraft (at least in winter) is scandalous. A bloke at Hotham on a laptop watching flightaware on the web and holding an $400 ICOM transceiver would have given these aircraft better service than our outrageously expensive Air Services Australia systems. Should we just trade "onesky" for a bunch of subscriptions to "Flightaware"?
Join Date: May 2008
Location: Australia
Posts: 565
Likes: 0
Received 0 Likes
on
0 Posts
But, the really interesting thing that I would have liked examined is why AsA can't track aircraft at Hotham, but the free web based Flighaware and Flightradar can.
Framer, the pilot completed all reviews and remedial training required of him by CASA. I agree that the time taken for the ATSB to produce this report brings into question either the competence or independence of the ATSB into question. But the inference that the pilot was either substandard or allowed to continue flying improperly while the investigation was underway is scurrilous.
The report into the MtHotham incident has the looks to me like it has been sanitised to make things simpler when the Essendon report is released. The Essendon report has either just been released to the DIP's or is on the eve of being released, so, effectively this report has been staged with the Essendon report.
This report, does, however, tie itself in knots trying to avoid blaming AsA or the airspace structure. Initially, (as I recall) AsA said there was no radar coverage in the area, now its saying there was, except for a critical 6 minute period. But, the really interesting thing that I would have liked examined is why AsA can't track aircraft at Hotham, but the free web based Flighaware and Flightradar can.
Another factor that has been overlooked is the lack of met data available at MtHotham. The BOM (largely based on AsA input) dropped the TAF service at Mt Hotham. Proper weather briefing at Mt Hotham may have completely changed the decisions made by the subject aircraft.
The pilot, after the incident, reported that the GPS was not functioning correctly and the report effectively confirms this, however, this report has made no investigation of the GPS equipment, nor the autopilot, nor the GPS /autopilot coupling. There is nothing in the report that challenges or disproves the hypothesis that improper operation of the GPS and / or autopilot contributed. Nor does the report give a robust investigation of RAIM. It makes the assertion that RAIM was available largely because other aircraft did not report difficulty. But given the critical role RAIM plays, and the brevity of typical RAIM outages, this report is deficient in its analysis of RAIM.
Finally, the lack of radar surveillance, meteorological information and air traffic control for such a busy airport with large charter aircraft (at least in winter) is scandalous. A bloke at Hotham on a laptop watching flightaware on the web and holding an $400 ICOM transceiver would have given these aircraft better service than our outrageously expensive Air Services Australia systems. Should we just trade "onesky" for a bunch of subscriptions to "Flightaware"?
The report into the MtHotham incident has the looks to me like it has been sanitised to make things simpler when the Essendon report is released. The Essendon report has either just been released to the DIP's or is on the eve of being released, so, effectively this report has been staged with the Essendon report.
This report, does, however, tie itself in knots trying to avoid blaming AsA or the airspace structure. Initially, (as I recall) AsA said there was no radar coverage in the area, now its saying there was, except for a critical 6 minute period. But, the really interesting thing that I would have liked examined is why AsA can't track aircraft at Hotham, but the free web based Flighaware and Flightradar can.
Another factor that has been overlooked is the lack of met data available at MtHotham. The BOM (largely based on AsA input) dropped the TAF service at Mt Hotham. Proper weather briefing at Mt Hotham may have completely changed the decisions made by the subject aircraft.
The pilot, after the incident, reported that the GPS was not functioning correctly and the report effectively confirms this, however, this report has made no investigation of the GPS equipment, nor the autopilot, nor the GPS /autopilot coupling. There is nothing in the report that challenges or disproves the hypothesis that improper operation of the GPS and / or autopilot contributed. Nor does the report give a robust investigation of RAIM. It makes the assertion that RAIM was available largely because other aircraft did not report difficulty. But given the critical role RAIM plays, and the brevity of typical RAIM outages, this report is deficient in its analysis of RAIM.
Finally, the lack of radar surveillance, meteorological information and air traffic control for such a busy airport with large charter aircraft (at least in winter) is scandalous. A bloke at Hotham on a laptop watching flightaware on the web and holding an $400 ICOM transceiver would have given these aircraft better service than our outrageously expensive Air Services Australia systems. Should we just trade "onesky" for a bunch of subscriptions to "Flightaware"?
Nothing to see here. No possible airspace structure or Airservices or BOM services issues. No possible equipment issues. But let’s feed the pilot competence rumour mill.
I’m no longer surprised or disappointed by the pap ATSB produces, usually years after the event. However, what continues to disgust me is so-called “professional” pilots who seem to enjoy casting aspersions on deceased colleagues. In real professions it would be a ground for disciplinary action and potential dis-barring.
In the case of the Essendon tragedy, there are formidable powers with very, very deep interests in another “nothing to see here other than implied doubts about the pilot’s competence” ATSB report. They’ll be loving any ongoing speculation about the pilot’s competence.
Old Akro and LB, you’ve gone off all half cocked there.
Yip, it doesn’t change the gist of my comment though that the powers that be will be hoping/ checking there are no holes in the paperwork that can be exploited by lawyers. ( ie a reason to delay the release of the report).
Rather than suggesting incompetence I was suggesting that time may have been taken to ensure vulnerabilities were identified and planned for.
Which inference was that? Stating that the pilot was identified as needing remedial training? That is what happened. I got it from the report and it is no doubt going to be a point of interest. No good will come from ignoring that part of the report or insulting people who raise it.
If you re read my posts you might see that rather than addressing the competence or incompetence of the pilot ( I have no idea), I was throwing out a hypothesis regarding the motivations that caused the report to take so long.
I cast no aspersions , the pilot was found ( rightly or wrongly) to require remedial training, that is written in the report and is a fact that was relevant when discussing why the report may have been delayed. Should we avoid repeating statements in a public report if they say something negative about someone? The whole point of my posts was about the ATSB.
Framer, the pilot completed all reviews and remedial training required of him by CASA
I agree that the time taken for the ATSB to produce this report brings into question either the competence or independence of the ATSB into question
But the inference that the pilot was either substandard or allowed to continue flying improperly while the investigation was underway is scurrilous.
If you re read my posts you might see that rather than addressing the competence or incompetence of the pilot ( I have no idea), I was throwing out a hypothesis regarding the motivations that caused the report to take so long.
However, what continues to disgust me is so-called “professional” pilots who seem to enjoy casting aspersions on deceased colleagues.
To quote Flightradar24:
Flightradar24 coverage is only available in areas where someone has installed an ADS-B receiver and shares data with the Flightradar24 network. We are unable to provide coverage in areas where no ADS-B receivers are installed.
Nitpicking, but a quick look at recent Hotham arrivals on flightaware shows that tracking stops at a position roughly coincident with where tracking stops in the ATSB report.
The report (characteristically for the ATSB) does not give enough data to check against their commentary. the ATSB is really good at switching between time, altitude and map location in a way that does not allow checking of their re-construction. The positions on the approach plates only have altitudes and not times, but it looks suspiciously like they did have tracking data for both aircraft during the time the report says they do not. It interesting that they show Est Sale radar screen shots, but not AsA radar screen shots. Nothing can be correlated.
Answered many times on this forum, most of what you see on Flightradar24 and Flightaware is derived from ADS-B data not SSR, and they largely rely on ADS-B receivers installed by hobbyists fed into their systems.
From FR24:
MLAT
In some regions with coverage from several FR24-receivers we also calculate positions of non-ADS-B equipped aircraft with the help of Multilateration (MLAT), by using a method known as Time Difference of Arrival (TDOA). By measuring the the time it takes to receive the signal from aircraft with an older ModeS-transponder, it's possible to calculate the position of these aircraft. Four FR24-receivers or more, receiving signals from the same aircraft, are needed to make MLAT work. MLAT coverage can only be achieved above about 3,000-10,000 feet as the probability that four or more receivers can receive the transponder signal increases with increased altitude.
In some regions with coverage from several FR24-receivers we also calculate positions of non-ADS-B equipped aircraft with the help of Multilateration (MLAT), by using a method known as Time Difference of Arrival (TDOA). By measuring the the time it takes to receive the signal from aircraft with an older ModeS-transponder, it's possible to calculate the position of these aircraft. Four FR24-receivers or more, receiving signals from the same aircraft, are needed to make MLAT work. MLAT coverage can only be achieved above about 3,000-10,000 feet as the probability that four or more receivers can receive the transponder signal increases with increased altitude.
The other interesting omission from the report is the tracking of the other aircraft. The report says that there were 5 aircraft conducting approaches to Hotham at about the same time. It does not say if any others flew missed approaches, or if they all flew the approach without difficulty and landed first time from the approach. The pilot of VH-OWN was without question a competent pilot with more experience on King Air's than most. If VH-OWN was the only aircraft with tracking / missed approach difficulties, then it would add credence to the pilots claim that there were GPS / autopilot faults.
VH-OWN had a C129a Garmin GPS 155XL (which at the time was completely legal for IFR). The report comments that the other 4 aircraft did not have the same tracking difficulty as VH-OWN but is deficient in not considering the GPS installations of the other 4 aircraft. If (for instance) they all had C146a GPS recievers (eg Garmin GNC430, Garmin GNX650, Garmin GNX 750, Garmin GNS480), then this would be a very significant fact that would deserve further investigation.
Also, the pilot of VH-OWN was criticised for not following the published missed approach. However, when I first flew into Hotham I had a charter pilot in the right seat who had very significant experience flying into Hotham. When we flew in VFR he pointed out to me that the published left turn missed approach was over rising mountainous forest. Whereas a right turn was over descending grassed terrain that led into a valley. His comment was that the right turn was a safer missed approach route that the published one and that it was frequently better to take the right turn and descend or remain at altitude under cloud, then climb into cloud over rising hostile terrain. It would be interesting to know if the pilot of VH-OWN was doing this. I guarantee that if I had any concerns about the operation of the GPS or autopilot, I'd turn right and remain visual until my thoughts were collected rather than turning left and immediately climb into cloud over rising "tiger country".
VH-OWN had a C129a Garmin GPS 155XL (which at the time was completely legal for IFR). The report comments that the other 4 aircraft did not have the same tracking difficulty as VH-OWN but is deficient in not considering the GPS installations of the other 4 aircraft. If (for instance) they all had C146a GPS recievers (eg Garmin GNC430, Garmin GNX650, Garmin GNX 750, Garmin GNS480), then this would be a very significant fact that would deserve further investigation.
Also, the pilot of VH-OWN was criticised for not following the published missed approach. However, when I first flew into Hotham I had a charter pilot in the right seat who had very significant experience flying into Hotham. When we flew in VFR he pointed out to me that the published left turn missed approach was over rising mountainous forest. Whereas a right turn was over descending grassed terrain that led into a valley. His comment was that the right turn was a safer missed approach route that the published one and that it was frequently better to take the right turn and descend or remain at altitude under cloud, then climb into cloud over rising hostile terrain. It would be interesting to know if the pilot of VH-OWN was doing this. I guarantee that if I had any concerns about the operation of the GPS or autopilot, I'd turn right and remain visual until my thoughts were collected rather than turning left and immediately climb into cloud over rising "tiger country".
Just because someone is competent at flying the aircraft does not necessarily mean that they are competent at flying an RNAV approach (or any other instrument approach, for that matter), despite it being in an aircraft that they can fly well.
Because the report doesn't seem to mention it, or I missed it, my questions would be:
1) How long had the pilot held an endorsement for RNAVs?
2) How many RNAVs had they done, and what was their recency on RNAVs? Especially in substantial weather.
3) How familiar was the pilot with conducting RNAVs with the equipment that was installed?