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Report out on Top End crash

Old 9th Apr 2019, 09:19
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Report out on Top End crash

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Old 9th Apr 2019, 23:30
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Report here.

https://www.atsb.gov.au/media/577587...-102_final.pdf
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Old 9th Apr 2019, 23:58
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"The risk mitigation provided by pairing a supervisory pilot with a trainee did not adequately address the weather-related risks.”
You can hardly blame the newbie then!
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Old 10th Apr 2019, 01:12
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There's already a long running thread about this tragedy running since it happened. Hope other newbies can gleam something out of their poor decision making!
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Old 10th Apr 2019, 01:33
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Once again ATSB investigators have shown their total misunderstanding of what Va is and what it isn't.
The claims in this report could be totally misleading to less experienced pilots.
Below is a cut and paste of AC 23-19A which is very clear in the lack of relationship between Va, stall and structural strength - except in one particular circumstance, that if the designer decides to us Va=Va min

"48. What is the design maneuvering speed VA?

a. The design maneuvering speed is a value chosen by the applicant. It may not
be less than Vs√ n and need not be greater than Vc, but it could be greater if the applicant chose the higher value. The loads resulting from full control surface deflections at VA are used to design the empennage and ailerons in part 23, §§ 23.423, 23.441, and 23.455.

b. VA should not be interpreted as a speed that would permit the pilot
unrestricted flight-control movement without exceeding airplane structural limits, nor
should it be interpreted as a gust penetration speed. Only if VA = Vs √n will the airplane
stall in a nose-up pitching maneuver at, or near, limit load factor. For airplanes where
VA>VS√n, the pilot would have to check the maneuver; otherwise the airplane would
exceed the limit load factor.

c. Amendment 23-45 added the operating maneuvering speed, VO, in § 23.1507.
VO is established not greater than VS√n, and it is a speed where the airplane will stall in a nose-up pitching maneuver before exceeding the airplane structural limits."

While Vo was not used when the C210 was certificated, the link below to the GA10 TCDS shows the large difference between Va and Vo which can occur purely depending on the Va speed choosen by the designer. In this case Va=133k CAS and Vo=98k CAS.
This essentially says if you pull to the stall at Va you will exceed the limit load factor and probably do structural damage.
Having said that, I have no idea how Cessna selected the speed they use for Va.
https://www.casa.gov.au/file/183956/...token=HuTWnu0t
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Old 10th Apr 2019, 02:11
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I would be questioning the 55 litre fuel burn for the 1 hour 50 something minute flight.

"The flight plan documented a planned altitude of 7,500 ft and a magnetic track of 082° direct to Elcho Island. The recorded fuel upload was 336 litres, with a planned fuel burn of 55 litres over the estimated flight time of 1 hour 52 minutes. The planned departure time was 1130."
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Old 10th Apr 2019, 05:34
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Joke

The owner of Air Frontier said he speaks with individual pilots to explain that there is no pressure to continue a flight, and they would be supported if they decided to return or divert. Likewise, the chief pilot of Air Frontier commented that from his standpoint, no job is worth pushing the limits for’. He felt, ‘if the weather’s no good get them to delay it’. He said they wanted the pilots to stay on the ground rather than try to push it in marginal weather situations.

everyone knows what the truth is.
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Old 10th Apr 2019, 06:29
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They obviously left some of the quote off

The owner of Air Frontier said he speaks with individual pilots to explain that there is no pressure to continue a flight
but if they don’t they won’t have a job anymore.
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Old 10th Apr 2019, 06:31
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A chief pilot is meant to be there for his/her drivers, to lead them, teach them and pass on many years of wisdom, did this CP do that in this case? We'll never know! Commercial,pressure is ALWAYS present, a lot of times we don't have the luxury of saying ....nah not gunna go, too risky!
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Old 10th Apr 2019, 08:14
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wishiwasupthere,

You reminded me and I just checked the logbook....20 years ago last week. It was my first flight for real in the C210 in wet season - I'd been checked to line for a couple of days and had done some short runs to Daly River and back, weather around but fairly benign. I had 800 odd hours at the time from down south, including some IFR.

I had an early afternoon Batchelor departure, Oenpelli, Bulman, Ngukurr, Borroloola, and to return the last part NVFR into Batchelor (the C210 wasn't IFR).

The late knockemdowns were in full swing and it was scud running around as far as Ngukurr (pre GPS) then on to Borroloola. BIG storms around. By this stage it was getting late and got away from BRL pretty much at dusk to be faced with a wall of black. Lighting everywhere. I felt the pressure to go, but that was internal, part pride, part wanting to get the job done.

I poked around and decided that Territory VFR at night for 2.5 hours wasn't going to cut it so turned back, shut down and made the phone call. I was soaked to the skin in the rain. Nervously I said, it's thick storms and its now dark, it was barely VFR getting here, I'm not happy going back at night.

"No problem, grab a hotel room, have dinner and come back in the morning. Keep all receipts" was the reply.

I got a room at the pub, ate dinner in the "less uncivilised" side of the bar/cage, and slept well and the next morning arrived back in Batchelor, and it wasn't an issue.

Not many of my fellow pilots in the Top End had such experiences with their managers. I was lucky.

PS... I didn't work for Air Frontier!
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Old 10th Apr 2019, 11:09
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Originally Posted by machtuk View Post
A chief pilot is meant to be there for his/her drivers, to lead them, teach them and pass on many years of wisdom, did this CP do that in this case? We'll never know! Commercial,pressure is ALWAYS present, a lot of times we don't have the luxury of saying ....nah not gunna go, too risky!
Most chief pilot's I have worked for have been nothing more than a lap dog to upper management and could not give a shit about the line pilots.
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Old 10th Apr 2019, 13:16
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To any new or new-ish GA pilots:

Please don't neglect to listen to that uncomfortable feeling in your gut when a situation just doesn't feel right. You will need to learn to balance this feeling with knowledge gained from experience, but you can never ignore it. Almost every bad situation I have ever been in has been preceded by this uncomfortable gut feeling.

The company you work for is probably under pressure from pilot turn over, financial pressure and so on. They probably won't be able to provide you with training pilots who have decades of experience. However the people in these roles will be doing the best they can with the experience they have.

But do not forget there are companies that will take advantage of you. If your boss doesn't pay you properly ( https://www.fwc.gov.au/documents/doc...f/ma000046.pdf ) there is a fair chance they don't give a rats about your career or personal wellbeing.

As the ATSB report stated in this case - it took them many hours to inform the next of kin of one of the pilots because nobody had bothered to ensure the paperwork was in order before he commenced flying.
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Old 10th Apr 2019, 13:40
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Very interesting to compare this accident report....to this one https://www.atsb.gov.au/media/24852/198300051.pdf
How times have changed.
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Old 10th Apr 2019, 23:16
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The investigation identified that medication the left seat pilot was taking was not recorded in his medical file.
While not stating this as a contributory factor, the report mentions twice (p.4 and p.24) that the pilot's DAME was unaware that he (the pilot) was taking a prescription medicine.

Are the ATSB really that naive? Given most of the pilot group now think of AvMed with distrust and contempt of biblical proportions, are the ATSB really unaware that the "tell your DAME nothing" attitude is prevalent?
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Old 11th Apr 2019, 00:25
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The report makes no mention of an "approved" load restraint system used to secure the coffin in situ, prior to departure.

The C210 has three rows of seats, where the front row was occupied.

An adult coffin is longer than two rows of seats, and must be secured to the seat rails, at a minimum.

More detailed information would benefit the industry.
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Old 11th Apr 2019, 01:27
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Originally Posted by Dora-9 View Post
Are the ATSB really that naive? Given most of the pilot group now think of AvMed with distrust and contempt of biblical proportions, are the ATSB really unaware that the "tell your DAME nothing" attitude is prevalent?
agreed. This part in particular gave me a good laugh:

The following extracts from CASA-developed brochures are particularly relevant to pilot medicals. DAMEs and pilots together should foster a culture where it is likely that pilots will feel comfortable disclosing medical problems, even if they may impact on their ability to maintain an aviation medical.Your DAME...will expect you to answer both written and verbal questions, honestly and fully...





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Old 11th Apr 2019, 02:27
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Originally Posted by BEACH KING View Post
Very interesting to compare this accident report....to this one https://www.atsb.gov.au/media/24852/198300051.pdf
How times have changed.
I recall that accident as I few with the Pilots son many years latter, very thorough report but even the son said the family where at a loss (no pun intended) as to what happened?
I also recall one of GAM's AC50 breaking apart mid-flight some years ago in Northern Vic, knew Knotty very well, that was a hell of a shock:-(
Sadly flying is risky, it's how we manage those risks to an acceptable level that can make a difference.
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Old 11th Apr 2019, 06:02
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Risks not managed well in FNQ a few days ago.?
Unless there was engine failure, putting him into the scrub, or medical issue, looks like the usual.
Rising terrain and lowering cloud . I know some folk who wished to track in the opposite direction, and never left the ground. The WX was crappy and clamped right down on the hills. With dzl.
Vale the pilot !
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Old 11th Apr 2019, 23:21
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In my 10 years in the top end, I recall many times having to divert around wx and with the odd turn-back. On many occasions it was best even when operating IFR to stay below the base which was often high, maybe 6 to 8000ft. At least at the lower levels you could see the rain/storm areas and divert around them. Any thought of trying to climb above it was a dream unless very early in the day.
I recall once going 150nm to the SW of KN at low levels in a jet, before finding a break and climbing to 390 and then having to dodge the tops! For those in piston singles and twins even with radar it was a poor choice to try and climb which sadly in this accident seems to have occurred. One would be far better off staying low and flying around the wx. No way would I have ever climbed IMC in such wx.
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Old 12th Apr 2019, 01:26
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Originally Posted by zzuf View Post
Once again ATSB investigators have shown their total misunderstanding of what Va is and what it isn't.
The claims in this report could be totally misleading to less experienced pilots.
Below is a cut and paste of AC 23-19A which is very clear in the lack of relationship between Va, stall and structural strength - except in one particular circumstance, that if the designer decides to us Va=Va min
I never knew that! [embarrassed smilie here]

I have always thought of Va as the speed where if you applied full control deflection, the surface would stall before it could provide enough force to exceed the max load factor of the aircraft meaning you could safely use full deflection of controls below Va.

"knowing" that, I recall being confused about the difference between the Citabria and Decathlon - they have the same stall speed and same Va yet the Citabria is limited to +5G and the Decathlon is +6G. I recall thinking, "shouldn't the Va be lower for the Citabria in that case?".

I am assuming (now) that the reason for the same Va despite different load limits, is because they chose to define Va to be the same for both aircraft (due to the Decathlon being derived from the same airframe).

I am now also assuming that despite being at or below Va I *can* exceed max G if I use full deflection inputs (is that correct?).

Last edited by jonkster; 12th Apr 2019 at 01:31. Reason: bad grammar
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