DHC Beaver down in Hawkesbury
It will be interesting to see what they can infer from all of this. There are many plausible yet unprovable scenarios that this will have to remain an open finding.
Having flown Beavers, the dreaded flap selector valve position theory appealed most but it seems that at impact the flaps were at approximately 15 degrees - the so called “climb” setting, thus blowing that theory out of the water.
Why the turn back into JB? Maybe a request from the happy and fun passengers to fly in there for a look, cheerful pilot eager to please has a brain snap and isn’t concentrating but chatting and enjoying the day suddenly finds himself in a bad place with no way out?
The theory of the pilot being knocked out by an exuberant passenger, while plausible, seems difficult to accept. In all likelihood, he would have been wearing a chunky noise cancelling headset, not leaving much of the head exposed to a blow.
Having flown Beavers, the dreaded flap selector valve position theory appealed most but it seems that at impact the flaps were at approximately 15 degrees - the so called “climb” setting, thus blowing that theory out of the water.
Why the turn back into JB? Maybe a request from the happy and fun passengers to fly in there for a look, cheerful pilot eager to please has a brain snap and isn’t concentrating but chatting and enjoying the day suddenly finds himself in a bad place with no way out?
The theory of the pilot being knocked out by an exuberant passenger, while plausible, seems difficult to accept. In all likelihood, he would have been wearing a chunky noise cancelling headset, not leaving much of the head exposed to a blow.
I doubt that the pilot could be knocked out by accidental contact with a camera, and highly unlikely there was intentional interference.
I’m wondering if there was accidental manipulation of the controls by the front seat passenger. Say, for whatever reason, the pilot has to make the steep right turn. The passenger could have inadvertently put pressure on one of the rudder pedals ( the yoke is throw-over), either but turning his torso to the right to watch or photograph out the window. Rotating the torso to the right usually causes, involuntarily, the right foot to push down. Alternatively, the passenger, unused to steep banking, tries to maintain a vertical posture, with a similar result, pushing on the right leg.
The pilot enters a steep bank, 60 or more degrees to the right, the passenger “applies” right rudder.
Of course, only speculation of possibilities, but no further stretched than the knockout theory. It also depends if the right side rudder pedals were operational.
I’m wondering if there was accidental manipulation of the controls by the front seat passenger. Say, for whatever reason, the pilot has to make the steep right turn. The passenger could have inadvertently put pressure on one of the rudder pedals ( the yoke is throw-over), either but turning his torso to the right to watch or photograph out the window. Rotating the torso to the right usually causes, involuntarily, the right foot to push down. Alternatively, the passenger, unused to steep banking, tries to maintain a vertical posture, with a similar result, pushing on the right leg.
The pilot enters a steep bank, 60 or more degrees to the right, the passenger “applies” right rudder.
Of course, only speculation of possibilities, but no further stretched than the knockout theory. It also depends if the right side rudder pedals were operational.
Some months ago there was a prominent member of an aviation organization getting around sprouting that there was a photo on the front passengers’ camera that showed the pilot slumped over the controls. I can’t help but think that the new shareholder got wind of this. Said photo doesn’t appear in the ATSB report. I wonder how on earth this rumour got started!
It also depends if the right side rudder pedals were operational.
In fact I cannot remember a Beaver that had them removed, disabled or stowed.
A little amusing segue, if that's okay. This Beaver was once with Seaplane Safaris. Chief pilot was S.A. He was walking down the pontoon at Rose Bay, about to do a check on a new recruit. Reaching the end of the deck he suddenly pushed the unsuspecting bugger in. Then threw him a life jacket, saying put that on if you can. Well the near drowned rat clambered straight out in a fury, saying WTF did you do that? Answer - Because CAsA did it to me last week.
So at what point was the pilot incapacitated? Before the aircraft made the turn into Jerusalem Bay? If so, it is astounding that the aircraft turned right and then flew for a further kilometre before banking steeply into a right turn. And how exactly was this knock out blow accidentally delivered? An elbow to pilot's head? While the Beaver is not a particular spacious aircraft there is a good 30-40 centimetres shoulder-to-shoulder separation between the two front occupants. The maximum extension of someone's elbow from their shoulder is about one sixth of their height. Importantly, the maximum extension occurs when the elbow is extended horizontally; in other words, when it is oriented towards the other occupant's shoulder. Raising the elbow to orient it towards the other occupants head shortens the horizontal extension by about 15 per cent (it varies depending on the height difference between the two occupants). While both Cousins and his eldest son were stocky fellows they weren't particularly tall. I just can't see how one of them could have elbowed the pilot's head.
Could someone have biffed the pilot with the camera? The Canon EOS 40D is not a particularly bulky camera (the body weighs in at around 750g). Based on the photo in the interim report it looks like it's fitted with the bog standard 50mm EF lens. It's hard to see how a passenger could have inadvertently clocked the pilot with that. When it comes to the myriad ways in which an aircraft can accidentally come to grief, it's best to never say never, however, that theory just doesn't appear to be plausible.
What I'm more interested in is:
1. Why was the track offset to the left rather than down the middle of Cowan Creek per Sydney Seaplanes' recommended flight paths from the Authorised Landing Area register?
2. Why did the sequence of photographs stop shortly after the right turn over Little Shark Rock Point started?
I'm wondering if the left offset was to accommodate the pax's photography out the right hand side? Was the 'plan' to execute an orbit over Little Shark Rock Point to further accommodate photography?
This is pure speculation but I'm wondering if the pax inadvertently dropped the camera shortly after that turn started. A dropped camera, a bit of shuffling around to retrieve it, pilot temporarily distracted and head down for a moment and then head up and temporarily disoriented and he's rolled out of the turn into the wrong bay. I'd argue that is a more likely sequence than the knock out. And it certainly wouldn't be the first time something like that has caused some grief on a flight.
Any old how, absent a CVR I suspect that we'll never get to the bottom of this one, as lucille has opined, the findings will be largely speculative I think.
Last edited by MickG0105; 21st Dec 2018 at 10:06. Reason: Format tidy up
[Seems like this site does not respect BB Codes so I'll revert to posting an image]
For what it is worth I have done some calculations on the data given in the interim report, Table 1. These give the ground speed and track between the Lat/Long positions over time. There are a number of wind estimates given in the report, I have used a wind of 15kt/025 to calculate the airspeed and heading from the ground speed and track.
The error terms are based on the photo time resolution of one second. So a gap of, say, 10 seconds between photographs will actually be somewhere between 9 and 11 seconds. There will be other uncertainties as well, not accounted for here.
The first column is the photograph number pairs given in the interim report, Table 1. Numbers 409 and 411 are missing from the sequence.
Image as [code] is not rendered properly on this site.
I don't know anything about DHC-2 operations but perhaps someone here could elaborate on whether these speeds and
rates of climb are typical, and at what power settings, given the aircraft was at, or very close to, MTOW.
For what it is worth I have done some calculations on the data given in the interim report, Table 1. These give the ground speed and track between the Lat/Long positions over time. There are a number of wind estimates given in the report, I have used a wind of 15kt/025 to calculate the airspeed and heading from the ground speed and track.
The error terms are based on the photo time resolution of one second. So a gap of, say, 10 seconds between photographs will actually be somewhere between 9 and 11 seconds. There will be other uncertainties as well, not accounted for here.
The first column is the photograph number pairs given in the interim report, Table 1. Numbers 409 and 411 are missing from the sequence.
Image as [code] is not rendered properly on this site.
I don't know anything about DHC-2 operations but perhaps someone here could elaborate on whether these speeds and
rates of climb are typical, and at what power settings, given the aircraft was at, or very close to, MTOW.
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Maybe
After take off it looks like the pilot planned to stay to the left of Cowan Creek to facilitate a turn back towards Cottage Point. Why, to shorten his track miles back to Long Reef and Rose Bay climbing out down Coal and Candle Creek and or to allow the front seat passenger with the camera to take some overhead photos of Cottage Point the place they just had a very nice lunch.
In the turn the pilot miss identified Jerusalem Bay for the main river. Even after spending a lot of time in the area this is still possible to do, as at low level the forks in the river at different spots can look similar. The very experienced pilot has then found himself in the middle of a boxed bay somewhat heavy at low level with a 10 to 15 knot tail wind and simply stalled in the turn with no chance of recovery.
A fact the ATSB has not mentioned is that this very experienced and comportant pilot
had an unfortunate and serious landing accident at Rose Bay in the company C-208 just a few days before the accident in question. (Four months to repair) Why mention this, maybe it was playing on his mind at the time rather than the job in hand.
We will most likely never know.
Last edited by Wandering giant; 21st Dec 2018 at 22:02.
Sunny #285..in jest?
Actually you DO need an AOC to take photographs from an aircraft. Reg 206 re commercial activities .....Photography
CAsA Prosecutor, not under oath..." NO person can take a photograph from an Aircraft in Australia with out a CPL and an AOC"
Too bad if your profession and income happened to be derived from photography
Thats CAsA for ya...any old BS will do.!
Expect a new reg to be promulgated soon...
' No person sitting next to the pilot in command may use a camera / iPhone/ iPad or any image making device in the cockpit of an Australian registered aircraft.' This is an offence of strict liability 50 pp ($10K)
Most folk wont buy the camera KO scenario... but CAsA probably will.. There might just be a teeny weeny possibility so we/casa will need to eliminate that "risk"
Actually you DO need an AOC to take photographs from an aircraft. Reg 206 re commercial activities .....Photography
CAsA Prosecutor, not under oath..." NO person can take a photograph from an Aircraft in Australia with out a CPL and an AOC"
Too bad if your profession and income happened to be derived from photography
Thats CAsA for ya...any old BS will do.!
Expect a new reg to be promulgated soon...
' No person sitting next to the pilot in command may use a camera / iPhone/ iPad or any image making device in the cockpit of an Australian registered aircraft.' This is an offence of strict liability 50 pp ($10K)
Most folk wont buy the camera KO scenario... but CAsA probably will.. There might just be a teeny weeny possibility so we/casa will need to eliminate that "risk"
I was near Cottage Point today heading north and witnessed a Beaver taking off. My god the climb rate is so low, be it due to normal performance or reduced power takeoffs! The terrain all starts to look the same from the lower levels and it comes as absolutely no surprise that the pilot may have kept going straight ahead by accident into Jerusalem Bay and not veered left back towards Cottage Point, particularly if you hadn’t done that maneuver a few times before. It’s all very deceiving and all the bays start to look the same.
From the ATSB website today (bolding is mine): https://www.atsb.gov.au/publications...r/ao-2017-118/
Update published: 31 March 2020
The ATSB investigation into the collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW, on 31 December 2017 is continuing.
The ATSB external review process commenced on 20 December 2019 and provided directly involved parties (DIPs) the opportunity to comment on the draft investigation report and present any evidence in support of their comments for incorporation into the final report. During the report review process period, some additional evidence was obtained by the ATSB that requires further research and analysis to ascertain its relevance and influence on the accident.
This has required an extension to the intended timeframe that the ATSB will be able to complete the final report. The ATSB intends to complete this analysis and provide DIPs with the opportunity to consider and provide comment on the new information if deemed relevant.
The additional work is anticipated to be completed in the second quarter of 2020.
Update published: 31 March 2020
The ATSB investigation into the collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW, on 31 December 2017 is continuing.
The ATSB external review process commenced on 20 December 2019 and provided directly involved parties (DIPs) the opportunity to comment on the draft investigation report and present any evidence in support of their comments for incorporation into the final report. During the report review process period, some additional evidence was obtained by the ATSB that requires further research and analysis to ascertain its relevance and influence on the accident.
This has required an extension to the intended timeframe that the ATSB will be able to complete the final report. The ATSB intends to complete this analysis and provide DIPs with the opportunity to consider and provide comment on the new information if deemed relevant.
The additional work is anticipated to be completed in the second quarter of 2020.
Last edited by 0ttoL; 31st Mar 2020 at 05:09. Reason: formatting
The additional work is anticipated to be completed in the second quarter of 2020.
Three and a half to four years. Six dead.
About par for ATSB.
Once you visit the creek / waterway they were operating in by boat and compare it to the flight path, you’ll quickly realise what happened and why. My gut feel is that the report will merely discount options, rather than list potential options and leave the reader to decide the obvious...
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Sunny, the camera would have to be massive to be any problem. NOO used to have single controls ( Pedals were inserted and held with a wingnut) and the column coming from the floor in the centre over in front of the pilot. It has a throw over switch to move the yoke over to the other seat.
Miss-handled flap action and being in the centre of the valley with not enough room for a fully loaded slow turn inside the valley peaks, would be my (Beaver experience) guess.
The flap action has been mentioned before but discounted because the flaps were found at the take off or climb position. NOO when it was used on AG work had the modified setup that always had down selected. I haven't seen a float equiped Beaver with it fitted. It used a motorcycle brake lever to pull the flap position to up before pumping hyd. main lever. A heavily loaded Beaver sometimes needs more than takeoff or climb flap, depending on the situation. With Flap down and flying slowly, a quick couple of pumps moving the flaps up would stall the aircraft. If the flap control lever was still in the up position this could have happened easily.
This has previously happened to AG machines, usually taking off. In the early days of Beaver AG ops it happened a few times, It was directed then flaps should be set at take off before roll started. Standard practice was to have flaps set with just a couple of pumps then as flying speed reached a couple of pumps had the aircraft flying. As mentioned before aircraft were modified in both NZ and Oz.
With no obvious cause my theory would be not enough room for a slow heavily loaded turn inside the valley, trying to tighten the turn radius by pumping flaps down, they went up instead of down (due flap movement lever in the wrong position) and stalled.
Miss-handled flap action and being in the centre of the valley with not enough room for a fully loaded slow turn inside the valley peaks, would be my (Beaver experience) guess.
The flap action has been mentioned before but discounted because the flaps were found at the take off or climb position. NOO when it was used on AG work had the modified setup that always had down selected. I haven't seen a float equiped Beaver with it fitted. It used a motorcycle brake lever to pull the flap position to up before pumping hyd. main lever. A heavily loaded Beaver sometimes needs more than takeoff or climb flap, depending on the situation. With Flap down and flying slowly, a quick couple of pumps moving the flaps up would stall the aircraft. If the flap control lever was still in the up position this could have happened easily.
This has previously happened to AG machines, usually taking off. In the early days of Beaver AG ops it happened a few times, It was directed then flaps should be set at take off before roll started. Standard practice was to have flaps set with just a couple of pumps then as flying speed reached a couple of pumps had the aircraft flying. As mentioned before aircraft were modified in both NZ and Oz.
With no obvious cause my theory would be not enough room for a slow heavily loaded turn inside the valley, trying to tighten the turn radius by pumping flaps down, they went up instead of down (due flap movement lever in the wrong position) and stalled.
Per the above from Super Cecil, I don't profess to understand the flap situation on this Beaver, and that may have been a factor in the last, steep, tight turn which failed.
I'm wondering why they went from flying North to then turning 270deg to the Right and end up heading West into Jerusalem Bay and the accident site.
Was this a standard departure path from this location? (No, according the ALA register in the ATSB report)
Did something happen onboard which meant the right turn continued more than usual?
I'm not a seaplane pilot either, but if faced with a box canyon situation, wouldn't it be better to pull power and land on whatever water remains than to try tight 180 turn at low level?
We may never know the answers, but I, like many, would like to know as much as possible to avoid it in future. It's yet another very sad aviation event.
I'm wondering why they went from flying North to then turning 270deg to the Right and end up heading West into Jerusalem Bay and the accident site.
Was this a standard departure path from this location? (No, according the ALA register in the ATSB report)
Did something happen onboard which meant the right turn continued more than usual?
I'm not a seaplane pilot either, but if faced with a box canyon situation, wouldn't it be better to pull power and land on whatever water remains than to try tight 180 turn at low level?
We may never know the answers, but I, like many, would like to know as much as possible to avoid it in future. It's yet another very sad aviation event.
As it happens VH-NOO popped up on FR24 as a DHC2 this morning at Moorabbin. A quick check at CASA revealed its a new DA40 registered to Learn-to-fly. In the UK I think regos are never re-issued? Maybe it should be a policy here for any aircraft involved in a fatal accident.
With all due respect to the industry and those affected, we would be running out of registration marks if that was the case here.