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ATSB clearly holds back Mt Hotham incident report

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ATSB clearly holds back Mt Hotham incident report

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Old 29th Jun 2018, 03:10
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I cast no aspersions , the pilot was found ( rightly or wrongly) to require remedial training,
Nitpicking, but the pilot was recommended to undrgo remedial training by the CASA FOI, not found to require it. What else is the CASA FOI going to do? The CASA approved testing officer did not make the same recommendation.

The pilot had 2,500 hours on King Air aircraft and a very large part of that was in VH-OWN. Does anyone want to take a bet on whether the CASA FOI who recommended remedial training had more experience or was better qualified than the pilot in question? What remedial training does one give a 7,500 chief pilot who has run his own charter company and has 2,500 King air hours? And who conducts the training? There are 38 B200 aircraft on the Australian register. How many of those are driven buy pilots with 2,500 hours on type?
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Old 29th Jun 2018, 03:22
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Then they - FR24 & FA - must have been using MLAT, given they don't get a feed of RADAR data from Airservices.
I commonly use Flightaware. I'm not as familiar with flightradar. In Flightaware's track log it often lists "AUSATC (Radar)" as a "reporting facility". I would expect that Flightradar gets the same data.

Once again, my 3 year old memory thinks that flight aware showed the position of VH-OWN & VH LQR based on "AUSATC(radar)" in the period during which the ATSB report says that AsA did not have information.

Last edited by Old Akro; 29th Jun 2018 at 08:19. Reason: typo
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Old 29th Jun 2018, 04:02
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Doesn't the report mention that the RADAR tracking used in the report was Military, and not available to AsA? I don't see a conspiracy about the Tracking data.
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Old 29th Jun 2018, 06:37
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Originally Posted by Old Akro
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..
Has that charter pilot contacted the procedures designers in Airservices and discussed his observations?

Given each site is first subject to an assessment process by them before designing a procedure, that procedure then itself subject to an assessment process then flight tested, to me its likely there is a valid reason for the missed approach to be where it is and not where your mate thinks it should be.

Perhaps there is something he is unaware of. Or if he feels a mistake has been made or there is a better design, why not bring it to the attention of the designers?
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Old 29th Jun 2018, 06:58
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Originally Posted by 717tech
Doesn't the report mention that the RADAR tracking used in the report was Military, and not available to AsA? I don't see a conspiracy about the Tracking data.
I seem to recall that around this time AsA took a few of the RAAF radars out of their system because they weren’t up to their standards. So in essence, someone thought it was safer to have no radar.

The report is quite short and doesn’t cover much technical detail. 3 years seems a bit long for such a report. It was also hardly touched on that the ATC didn’t mention to the pilot that they were off track. This happened about 10 years ago with a fatal crash. AsA promised that they fixed everything back then.
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Old 29th Jun 2018, 08:18
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Has that charter pilot contacted the procedures designers in Airservices and discussed his observations?
Actually spoke with him today to confirm. He was taught this by a Qantas Link Captain who said the Qantas Link procedure was to turn right over the more open, falling terrain. Seems strange to me that Qantas Link would not follow the published procedure. Maybe we'll get someone who can comment first hand. But, if I had any visibility and needed to go around, I'd absolutely go right instead of left. Have a look at Google Earth. Measure 8nm due South of the airport. Thats the missed approach point HOTEH. HOTEI, (which is where this incident is centered), is just south of Omeo. Would you rather turn right or turn left to get from Mt Hotham airport to Omeo?

The ATSB have enough information to know whether or not this is common practice. The first step is to see if any of the other 4 aircraft flew a missed approach on the day - which is a critical piece of the puzzle that they ignore. The second step is to look at some other radar returns. This is supposed to be their special subject. Reviewing the approach design is a valid thing for the ATSB to have done for this incident.
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Old 29th Jun 2018, 09:28
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It was also hardly touched on that the ATC didn’t mention to the pilot that they were off track. This happened about 10 years ago with a fatal crash. AsA promised that they fixed everything back then.
Re an incident 10 years ago, you might be thinking of a different situation i.e. an aircraft enroute from Nowra deviating off track.

From this report:
Once the aircraft began manoeuvring below 10,000 ft in the vicinity of Mount Hotham, including when conducting the approach, the controller could not always see them on their surveillance display.
and
Due to the size of the area under the controller’s jurisdiction, the scale of the surveillance display being used by the controller and a possible focus on higher priority tasks may have restricted their ability to detect the inaccurate tracking and position reports by the pilot of OWN.
I said in my earlier post #29 the ATC sector covers quite a large area, so given the scale of the display and patchy surveillance coverage I suspect the YHOT procedure waypoints would be contained within quite a small area, so not easy to closely monitor whether someone is exactly on them, particularly with other traffic management etc. responsibilities.
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Old 29th Jun 2018, 09:34
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Controller’s “jurisdiction”.

Dead give away of an accident investigator and air service provider who have no clue.
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Old 29th Jun 2018, 10:02
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Originally Posted by Old Akro
The ATSB have enough information to know whether or not this is common practice. The first step is to see if any of the other 4 aircraft flew a missed approach on the day - which is a critical piece of the puzzle that they ignore. The second step is to look at some other radar returns. This is supposed to be their special subject. Reviewing the approach design is a valid thing for the ATSB to have done for this incident.
Interesting to read this one, and look at appendix B re flight paths:

Collision with Terrain Mount Hotham, Victoria 8 July 2005 VH-OAO
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Old 29th Jun 2018, 10:14
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You see, OA: The pilot of OWN was doing the same thing as that dude who flew his own bootleg approach and crashed in 2005.

Not Captain Midnight’s ”jurisdiction”.
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Old 29th Jun 2018, 10:33
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Interesting to read this one, and look at appendix B re flight paths:
indeed!!

Firstly, it looks like in 2005 AsA has very good radar coverage of the area down below 5,500 ft. what has AsA's radar coverage deteriorated so badly?? The 2005 report quotes AsA saying that reliable coverage is not available below 5500 ft, but in 2015 they say radar coverage is patchy below 10,000ft

Secondly, the Dash 8 (Qantas Link ?) flew a pretty unorthodox missed approach, but yet this was not commented upon. By the standard that the ATSB set on the Kingair report, the pilot would be crucified.

Thirdly, it doesn't support what I was told about the Qantas Link missed approach procedure.

Forthly, its apparent from the 2005 report that there were TAF's available plus a met station at Mt Hotham. Neither are available now.

Fifthly, the report notes CASA concerns and surveillance of the performance of the pilot. It should be noted that there is no similar section in this report which would suggest that CASA had no prior concerns with the pilot or the AOC holder.

Last edited by Old Akro; 29th Jun 2018 at 10:50.
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Old 29th Jun 2018, 10:48
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You see, OA: The pilot of OWN was doing the same thing as that dude who flew his own bootleg approach and crashed in 2005.
Absolutely nothing to support this assertion.

Firstly, if the ATSB was interested in doing a proper, diligent, transparent job of making the report, it would publish full flight paths - like it did in 2005. What rational reason would there be for not presenting the full picture?

Secondly,the Chieftan did not commence the approach conventionally. It appears that the Kingair did commence the approach correctly, but did not follow the prescribed approach or missed approach procedure. At the broadest view, this would be either due to the GPS / Autopilot malfunctioning as the pilot reported (the report notes that when the aircraft flew the same approach in VFR after the incident that there were anomalies in its performance, but the report has not provided any details). Alternatively the pilot through lack of competence or through willful choice, did not fly the published approach. In 2005 there was significant evidence that the pilot created his own procedures. No such evidence has been tendered in this report.

The report is kind of sort of weakly suggesting that there was fault with the C129a Garmin GPS / Autopilot interlink. But now that C129a GPS units are no longer legal for IFR its an assertion that can no longer be proven or disproven.
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Old 29th Jun 2018, 11:27
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Originally Posted by Old Akro
But now that C129a GPS units are no longer legal for IFR
Really?
Since when?
Would you be able to point me in the direction of the information about this?

I've been using 145s for a little while now, so if there's been a change for 129s I've not seen it, and purely out of interest would like to.
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Old 29th Jun 2018, 12:20
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Originally Posted by Car RAMROD


Really?
Since when?
Would you be able to point me in the direction of the information about this?
CAO 20.18 Para 9D has the relevant blurb.

TSO C129a still perfectly fine for IFR in conjunction with a VOR or ADF back up.

Only aircraft built after Feb 2014 or systems installed in older aircraft after Feb 2014 are required to be TSO C145 or better.
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Old 29th Jun 2018, 12:31
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Akro, AsA has never had good coverage at Hotham - it's the radar feed from East Sale that provides the coverage.
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Old 29th Jun 2018, 12:38
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Originally Posted by Kiwiconehead
CAO 20.18 Para 9D has the relevant blurb.

TSO C129a still perfectly fine for IFR in conjunction with a VOR or ADF back up.

Only aircraft built after Feb 2014 or systems installed in older aircraft after Feb 2014 are required to be TSO C145 or better.
Thanks Kiwi.
That was my recollection. Not quite the sweeping statement that Akro made though.
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Old 29th Jun 2018, 12:56
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That was my recollection. Not quite the sweeping statement that Akro made though.
Yes, but you can no longer fly IFR without ADS-B, which requires a WAAS receiver. So, the practical reality that remaining C129a receivers are no longer the #1 GPS (if they are left in the panel) and no longer the autopilot coupled GPS.

I'm pretty sure VH-OWN has had the GPS 155XL removed now.
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Old 29th Jun 2018, 13:23
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Originally Posted by Old Akro
Yes, but you can no longer fly IFR without ADS-B, which requires a WAAS receiver. So, the practical reality that remaining C129a receivers are no longer the #1 GPS (if they are left in the panel) and no longer the autopilot coupled GPS.
.
Lots of people are fitting transponders with built in WAAS, completely self contained. Nothing changes nav wise for the aircraft.
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Old 29th Jun 2018, 13:57
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Originally Posted by Kiwiconehead
Lots of people are fitting transponders with built in WAAS, completely self contained. Nothing changes nav wise for the aircraft.
Not for IFR, certainly not IFR charter and definitely not IFR Charter pressurized.

The PBN requirements pretty much dictate a C146 navigation GPS. Its true you can still use a C129a GPS, but the diversion fuel requirements (especially under the proposed new regulations) become so impracticable as too make C129a boxes unusable for primary navigation.
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Old 29th Jun 2018, 15:14
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Kiwi, correct. You can have adsb transponders with standalone 146 inputs.

Look at the Trig series, Akro. Also Garmin too I recall. Plenty of Aussie IFR charter pressurised machines running around with those, and 129 Nav gps units.

There has always been alternate differences between 129/145. Nothing has changed.

You said that 129 gps isn't legal for IFR any more. Do you still stand by that statement?
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