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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, 22:46
  #61 (permalink)  
 
Join Date: Jul 2000
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Originally Posted by Old Akro View Post
Not for IFR, certainly not IFR charter and definitely not IFR Charter pressurized.
We have two in our fleet:
Turbine twin with the dual TT22 transponders fed by a TN70 remote WAAS. GPS in the panel is a Trimble 2101 I/O Plus - IFR Charter
Piston Pressurised twin with Dual KLN900s for nav and GTX335 with built in WAAS for ADSB.

Both still running charter quite happily - yes there are planning limitations with some destinations, but they are still legal.
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Old 30th Jun 2018, 05:22
  #62 (permalink)  
 
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This thread is supposed to highlight that the ATSB have again released a sub-standard report, that does not appear to have considered all relevant facts, that the report is not "transparent" in providing all data that would allow a reviewer to work through the voracity of the report and that yet again, it has failed to diligently examine the role of other government departments - primarily AsA. In this instance it has stopped short of the old practice of blaming a dead pilot, but it certainly does cast aspersions on the pilot without having properly prosecuted its case.

The most fundamental tenant of a scientific report is that a peer reviewer should be able to pick up a report and using the tabled data and / or details of methodology used, work through the report and reach the same conclusions. Currently, the ATSB reports fail this test. In recent years that have adopted the practice of only presenting the data that supports the conclusion of the report. The 2005 report on VH-OAO is a good demonstration. The OAO report tabled all the flight path data of all aircraft involved, not selected flight data of only the subject aircraft.

Regarding ADS-B, after so many posts and so much communication, I cannot believe that we are still going over it.
1. CASA mandated ADS-B for all IFR aircraft at ALL levels and all airspace types by 1 Feb 2017. Something that was unique in the world and 3 years or more in advance of any other country - notably the US and requiring technology that was different than the main markets (ie the US).
2. Like all other recent major "reforms" at the 11th hour when it was patently obvious that CASA's mandate was not practically possible to achieve, CASA backed down.
3. In order to try and save face, it introduced a convoluted web of exceptions that have made the whole affair a mess. From CASA:
The 2 February 2017 mandate still stands. CASA is introducing two instruments – one for domestic operators and one for international operators – that offer restricted, time-limited relief under specific conditions, which will come into effect on 2 February 2017. This is consistent with the action CASA has taken for every mandate introduced to help bring the aviation community on board and help address any concerns as new regulatory requirements are introduced.
All operators of non-ADS-B equipped aircraft that currently operate under instrument flight rules (IFR) will still need to make a decision about whether to equip, fly under the visual flight rules (VFR) only, or retire any unequipped aircraft. These instruments will give a limited number of domestic operators more time to make this decision but the 2 February 2017 mandate will still impact them – they will be restricted to lower level, uncontrolled airspace (Class G/under 10,000 feet) and controlled airspace around regional and metro Class D airports. The most fuel efficient options may not be available to non-equipped aircraft flying under IFR.
Currently, aircraft cannot fly above 10,000 ft without ADS-B. Unless you have one of the many CASA exemptions because there is no approved ADS-B fitment option. Dick Smith's Citation was probably the most famous example.

There are also restrictions on flying into control airspace. But probably more significant than the CASA restrictions are the unpublished AsA flight priority allocations. If you don't have ADS-B you will have lower priority than a rubber band model aircraft. GA is treated badly enough by AsA, but GA without ADS-B is rock bottom.

The second factor are the PBN rules, which if the proposed fuel margin regulations are approved will become dramatically more onerous. If you fly in the J-curve then your sheltered existence won't get this. But for the rest of Australia a C129a GPS means you need to carry fuel for diversion to an airport with a ground based navaid approach plus holding fuel. After the great AsA navaid shutdown, this can mean that some IFR flights just can't be done and meet the fuel reserve requirements. If the proposed fuel regulations are adopted, infringe this by 1 minute and you have committed a strict liability offence. Neither a remote mounted TN70 nor a TXP with integrated WAAS receiver will satisfy the PBN requirements.

Unlike the US, Australia requires engineering orders for ADS-B installation. I'd suggest that for most aircraft its cheaper to put in a used 430 and a ADS-B transponder than fit a remote WAAS box primarily due to the cost of engineering orders and metal work surrounding a non rack mounted remote box together with the install cost of an additional (vs replacement) GPS antennae. The TN70 is about AUD$3,500. Add probably $3,000 - $4,000 for install plus $2,000 - $3,000 for engineering orders and a factory refurbished 430 (which still seem to be readily available) at $9,500 is looking pretty good - or a secondhand GTN650 for about the same price. The 430 will have lower install cost and lower EO cost than the TN70.

Specifically regarding VH-OWN, I believe that the GPS installation was a source of friction between the pilot and aircraft owner and that is why the pilot refused to operate VH-OWN after the Hotham incident and how he ended up flying ZCR on the fateful day. I also understand that the owner of OWN had the GPS upgraded and ADS-B installed soon after the Hotham incident.
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Old 1st Jul 2018, 12:29
  #63 (permalink)  
 
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The most fundamental tenant of a scientific report is that a peer reviewer should be able to pick up a report and using the tabled data and / or details of methodology used, work through the report and reach the same conclusions. Currently, the ATSB reports fail this test. In recent years that have adopted the practice of only presenting the data that supports the conclusion of the report. The 2005 report on VH-OAO is a good demonstration. The OAO report tabled all the flight path data of all aircraft involved, not selected flight data of only the subject aircraft.
Do they purport to be a scientific report? I would have thought that the background investigation leads to a conclusion, then a report is prepared that states that conclusion and presents the data that leads to that conclusion. They are not presenting or initiating a debate. That has already happened. The OAO report tabled the flight path data of the other aircraft because it supported the conclusion, and was relevant. I would say that only the flight data of OWN was shown as it is the only one relevant. No other pilot on the day reported issues with their GPS or wandered about the sky trying to conduct an approach.
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Old 1st Jul 2018, 16:02
  #64 (permalink)  
 
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TIEW:
and presents the data that leads to that conclusion.
.

No. Presents all data, then an analysis of the data, possible conclusions, then your reasons for discarding the alternates. The final conclusion is the one that best fits ALL the available data. To do otherwise leaves the researcher open to the charge of cherry picking data to suit their preferred conclusion.
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Old 1st Jul 2018, 19:09
  #65 (permalink)  
 
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ATSB and its predecessors have never published reports like that. They publish their findings. Why should this one be any different? Just because you disagree with it?
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Old 1st Jul 2018, 22:04
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Do they purport to be a scientific report?
They used to purport to be a report of the outcomes of a scientific process. Jumping to a convenient or comfortable conclusion then finding “facts” to “support” that conclusion is not a scientific process. (I can show you reports with “data” that “support” the conclusion that white people are smarter than black people.)
I would have thought that the background investigation leads to a conclusion, then a report is prepared that states that conclusion and presents the data that leads to that conclusion.
Yeah - like the “background investigation” of the Whyalla Airlines Navajo that was based on old wives’ tales about piston engines and presented data that was hogwash. Many, many like that since then.

At least back then it was just structural incompetence. Now it’s special interest interference as well. So many people providing “data” to “support” a conclusion that happens to be convenient and comfortable for them. Everyone, that is, but the deceased pilot.

If there is litigation in the wake of the Essendon tragedy, it will be interesting to see what a rigorous fact-finding process and causal analysis turns up.
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Old 2nd Jul 2018, 04:32
  #67 (permalink)  
 
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The OAO report tabled the flight path data of the other aircraft because it supported the conclusion, and was relevant. I would say that only the flight data of OWN was shown as it is the only one relevant. No other pilot on the day reported issues with their GPS or wandered about the sky trying to conduct an approach.
How is the flight path of the aircraft that VH-OWN allegedly infringed (VH-LQR) not be relevant?? I would have thought that was the very definition of only showing one side of an argument?

The pilot of VH-OWN reported that the GPS and / or autopilot did not function correctly.
The following day, the pilot repeated the flight with a CASA test officer. The report notes that there were anomalies in the performance of the GPS / Autopilot, but not of the same severity as the flight in question.
The ATSB did not conduct its own flight tests.

In this circumstance, especially since the report criticises the pilots procedure entry, I would think that the flight path of other aircraft and specifically the flight path of the aircraft that VH-OWN came into close proximity is a central and critical part of a proper investigation. How can you criticise the pilot of VH-OWN without demonstrating that VH -LQR and the other aircraft flew perfectly and did not contribute?

How can the ATSB say the other aircraft had no GPS issues without considering what GPS receivers they had fitted? ie, was VH-OWN the only one still using a C129a receiver? Older GPS units and especially older GPS antennae tend to "see" fewer satellites. Was this a factor? A diligent report would consider this before dismissing the performance of the GPS as an issue.

Why is there no discussion about the closure of the Mt Livingstone VOR? It was pretty close to HOTEI and would have been a useful crosscheck for the GPS. Does the hostile terrain, poor radar coverage and pachy VHF coverage at Australia's highest certified airport deserve a review of whether the Mt Livingstone VOR should be added to the back-up network?

I also wonder if this report purposely omits some flight data, because if it showed all the flight data, it would demonstrate that there was better radar coverage than AsA has claimed and that AsA's inaction in warning either pilot would come under more scrutiny.


Why should this one be any different? Just because you disagree with it?
I don't disagree with the report. Its too bland to disagree with. But, I think its sub standard.

It kind of sort of finds some maybe potential unspecified fault with a dead pilot. It raises failings with AsA but then laughs them off in the conclusion and it waves off any issues with the radar infrastructure by suggesting its all been fixed now by the implementation of ADS-B. And it fails to consider any contribution of the withdrawal of met services from Mt Hotham. I just think it fails any test of being a robust, diligent, objective report. And the only reason I care is because I'm concerned its going to falsely set a precedent of poor piloting for the Essendon report - which is the main game.
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