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VH-YTM final report

Old 13th Aug 2019, 05:22
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VH-YTM final report

https://www.atsb.gov.au/publications...r/ao-2017-069/

DF.
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Old 13th Aug 2019, 06:00
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So sad and so unesesary -
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Old 13th Aug 2019, 07:34
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https://www.abc.net.au/news/2019-08-...crash/11407294
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Old 13th Aug 2019, 08:02
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I haven’t yet found the flaw in ATSB reasoning, but I used to do something like this sort of work years ago.

While I may well be mistaken, ATSB has come to some what appear to be startling conclusions;

1. Angel Flights are seven times more dangerous than ordinary private operations. These private operations themselves are more than twenty times more dangerous than charter and RPT.

This implies that Angel Flight pilots are seven times stupider than the general GA pilot population or, as ATSB seems to suggest, there is a reality distortion field around ATSB operations that makes people idiots (seven times stupider!) when operating an Angel Flight.

But wait! There’s more.... Table B5, Technical occurrences, shows that the aircraft knows it is on an Angel Flight compared to a private flight and being malevolent, responds by making things break or fail in flight. The possible exception may be the engine, which seems to be non sentient and fails without regard to who is driving or where they are going.

Then of course there is the weather, birds and wildlife, all of whom seem to have it in for angel flights.

I have to say I am not convinced because “category of operation” is a rather imprecise term. We are not comparing apples with apples I think. For example a private operator doing dozens of scenic s from his home airport is not exposed to unfamiliar airports and less than perfectly sunny weather. A fairer test would be to look at private flights that match Angel flight trip durations - say four hours there and back and compare those safety occurrence records rather than comparing angel flight with someone doing circuit training.

Anyway, that’s my opinion FWIW.
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Old 13th Aug 2019, 08:34
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If you really think that this isn't a case of an inexperienced operator uselessly plunging off into IMC (after just somehow miraculously not killing themselves in it minutes earlier) due to a perceived pressure that they were unable to accurately and effectively rationalise and mitigate, then you're kidding yourself.

I think that's the only really important part of the report. The stats and the like, I agree, seem pretty heavy handed and I'm not entirely sure what accuracy or even relevance I'd give them. At the end of the day the actions of the PIC were inexcusable. There is no safety related “fix.” What was carried out was a violation. In the future, there needs to be an assessment of what motivated the violation, and how to mitigate that risk in the future. If the answer to that is instituting tougher requirements, then that’s probably okay in my opinion. The death here was needless, tragic and genuinely avoidable.

That CCTV imagery is just genuinely horrifying. I can't fathom how anyone could rationalise launching BACK into that, with passengers, after so narrowly avoiding disaster and cheating death the first time; and yet it happened. Why?
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Old 13th Aug 2019, 08:58
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Junior LFA you are right. I have no problem with that. Similarly the previous accident I think. But how do you extrapolate from two fatal accidents in ten years of operation to “systematically unsafe”? That is where I may have issues.

I can’t help thinking that there is some well connected greaseball waiting to launch a taxpayer funded alternative to AF.

As for the statistics about RPT being dramatically safer, it probably is, but one A380 going down in Sydney CBD will change that. Accident occurrences in RPT are very infrequent but large. The Feyneman appendix to the Challenger report is still worth reading again and again.


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Old 13th Aug 2019, 09:02
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Originally Posted by Sunfish View Post
Junior LFA you are right. I have no problem with that. Similarly the previous accident I think. But how do you extrapolate from two fatal accidents in ten years of operation to “systematically unsafe”? That is where I may have issues.

I can’t help thinking that there is some well connected greaseball waiting to launch a taxpayer funded alternative to AF.

As for the statistics about RPT being dramatically safer, it probably is, but one A380 going down in Sydney CBD will change that. Accident occurrences in RPT are very infrequent but large. The Feyneman appendix to the Challenger report is still worth reading again and again.


I tend to agree with you WRT the data and the reasons why that is the focus of the report.
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Old 13th Aug 2019, 09:07
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The answer to AF’S problems might be what my Dad did for me and I did for my son and others have done for their kids......An insurance policy; “if you have had too much to drink, or don’t trust your driver, then call a cab, anywhere, anytime, we will pay the cab fare absolutely no questions asked.” I only ever availed myself of that maybe twice, my son with me likewise.

How difficult would it be for AF to have an IFR professional and suitable aircraft as a backup on call, so a volunteer can bail without letting their patients down if they feel things are getting beyond them?

Having someone on call would cost money, but there would still be lower costs than a full professional outfit.
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Old 13th Aug 2019, 09:10
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It’s beyond sad when the ATSB so shamelessly manipulates statistically insignificant data and coincidental clusters to support CASA’s knee jerk response to accidents during private ‘community service’ flights.
Imagine living with the worry that something at your workplace could be causing cancer. That's the reality for workplaces caught in a cancer cluster scare. The latest alarm has been raised at the ABC's Melbourne studios, three years after a cluster of 17 breast cancer cases at the ABC Brisbane headquarters forced the site's closure.

Cancer experts say that in 99.9 per cent of clusters investigated, there is no underlying cause found, meaning that most clusters are mere coincidence. But that's little solace to staff members comforting stricken colleagues and wondering if something in their work environment might be threatening their lives.
[My bolding.]

If CASA and ATSB were left to deal with this kind of stuff, mere coincidence and scaremongering statistics would be the basis of most regulatory activity. Oh wait...

So I’ll have a go at summarising the safety messages from the YTM tragedy:

1. Don’t fly in IMC if you don’t have a current IFR rating.

2. Resist external pressures to fly when you shouldn’t.

3. As a consequence of 1 and 2, always have a Plan B and a Plan C.

If only these lessons had been learnt before and some organisation were funded and responsible for aviation safety promotion - constantly and effectively repeating these messages and getting them across. Oh wait...

Last edited by Lead Balloon; 13th Aug 2019 at 10:38.
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Old 13th Aug 2019, 09:12
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Originally Posted by Sunfish View Post
The answer to AF’S problems might be what my Dad did for me and I did for my son and others have done for their kids......An insurance policy; “if you have had too much to drink, or don’t trust your driver, then call a cab, anywhere, anytime, we will pay the cab fare absolutely no questions asked.” I only ever availed myself of that maybe twice, my son with me likewise.

How difficult would it be for AF to have an IFR professional and suitable aircraft as a backup on call, so a volunteer can bail if they feel things are getting beyond them?
They already have a backup plan. Cancel the flight if there is any doubt. It’s not that hard! There is no urgency, that’s why they are not going by ambulance of the fly docs. That is made clear to all pilots and participants.

Last edited by Cloudee; 13th Aug 2019 at 09:41.
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Old 13th Aug 2019, 09:15
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The memorial to the victims should be a better service, not no service.
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Old 13th Aug 2019, 10:37
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Looking at the CCTV images in the report, the pure contempt this individual has for the lives of his passengers and himself is inexcusable. Whatever flight school turned out this product just 2 years before the accident should be very proud

Last edited by Mark__; 13th Aug 2019 at 11:48.
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Old 13th Aug 2019, 10:48
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Flight schools can't be held accountable for the decision making of a private pilot 3 years later.
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Old 13th Aug 2019, 10:49
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Correct: We should blame Angel Flight.
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Old 13th Aug 2019, 10:54
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Old 13th Aug 2019, 14:57
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r https://www.atsb.gov.au/media/577660...-069_final.pdf
https://www.atsb.gov.au/media/27144/aair198902571.pdf

The first link relates to the ATSB report just released on the crash of the Tobago at Mount Gambier in June 2017. The report took just under two years to produce and contained approximately 90 pages. The vast majority of the report had little to do with actual loss of control. No wonder it took two years of delay before the report was released. Some readers may consider much of the report was superfluous. Unless interested in the legal minefield exposed in the report, most ordinary pilots would prefer to bypass the heavy stuff in order to get to the guts of the accident and hopefully learn from it.

The second link relates to the ATSB report on the fatal crash of a Grumman Cougar in August 1989 where an engine failed shortly after takeoff at night and the pilot lost control. That report took 12 months to be released and covered just four pages.. In contrast, the difference between the length of the two reports is notable. In both cases the cause of the accidents was loss of control less than a minute after takeoff.
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Old 13th Aug 2019, 22:58
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Re the CCTV/Cam images; I have noticed with our own web cam that if there is some moisture on it then the image looks worse that what it does if you go outside and look with your eyes. All I'm saying is that there can be a difference and that difference may be behind a decision that ended up being wrong.
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Old 14th Aug 2019, 01:19
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Safety Digests have been telling us for yonks that experience is the key.
But CAsA doesnt believe that, just being a PPL, whatever yr experience, CAsA believes yr are bloody dangerous and do all the killing,
And now.! ..if you go Angel Flight this/ any PPL is 7 x more bloody dangerous..! Interesting "theory"
CAsA's reaction comes about because CAsA hate not being in Total Control and all times.
Once Pilot gets in the cockpit and starts up, a decision is made and there's absolutely nothing CAsA can do about it.
The pilot is exercising the PPL licence with incredibly stupid decision making
In both cases , both decisions to continue, were flawed and (tragically) fatal.
Its the decision making that is at fault. How to instil that into people.? Is there specific 'decision making' lectures for PPLs these days?
Maybe you just have to be a natural coward ( thinks, I could kill myself doing that !) and be 'risk averse' under certain circumstances...like entering IMC unqualified and pushing on in the coming dark, no NVFR.
Many years ago there was a run of CHT accidents in the Straits and Cape York, 7 of and 21 fatalities in less than a year.
Did CasA make any changes to the way CHT is conducted in remote areas...and vilify CPLs. No. That's just the way it is.
What was the title of the article regarding the fuel runout crash in Columbia, Bolivia?.. "Pilots, We can be heroes or murderers" Sums it up nicely
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Old 14th Aug 2019, 01:33
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Would it be safer if Angel Flight pilots held instrument ratings?

In the USA over 80% of private pilots hold instrument ratings when practically none do here.

Why? In the USA it is affordable because it is not bound up in bureaucratic bullsh#t that doubles the cost of gaining one.

A classic illustration of how over regulation diminishes safety by suppressing participation.

Air travel is the safest mode of mass transportation; your odds of dying in a plane crash are about one in 11,000,000. That's an average of about 110 people per year, and those numbers include private planes and non-crash related accidents in addition to commercial travel. In fact, you're more likely to be struck by lightning, with a one in 13,000 chance for your lifetime. That's why the ATSB report is so flawed. They doctor their statistics to suit CAsA's agenda.

If CAsA had the courage of their convictions they would just ban community service flights.

Children dying of cancer or on the road to see their specialist would be on their heads, not that they would give a sh$t.
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Old 14th Aug 2019, 01:54
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Those conditions don’t even look suitable for IFR flight.

Agreed on the webcam though. Air services give us a low quality low res image and keep the good ones for themselves. It would have been good to see the proper images.
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