Mooney accident pilot refused a clearance at 6,500'
Thread Starter
CLEARANCE NOT AVAILABLE is a reply you get from ATC only in Australia..
In five flights around the world I have only heard this terminology in this country.
The ATSB have effectively blamed the pilot and the ATC for this accident.
What is dishonestly not covered is the fact that the ATC was also responsible for aircraft in un controlled airspace at the same time. This clearly was a contributing factor.
A famous poster on this site, namely Bindook called the class C airspace above D “ roadblock airspace” He was correct. And now two lives have been lost.
The ATSB needs to re do this report and stop protecting the minister and AsA.
In five flights around the world I have only heard this terminology in this country.
The ATSB have effectively blamed the pilot and the ATC for this accident.
What is dishonestly not covered is the fact that the ATC was also responsible for aircraft in un controlled airspace at the same time. This clearly was a contributing factor.
A famous poster on this site, namely Bindook called the class C airspace above D “ roadblock airspace” He was correct. And now two lives have been lost.
The ATSB needs to re do this report and stop protecting the minister and AsA.
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The full report makes interesting reading.
A transcript of the actual radio calls would be very helpful. Times are not given for most of the events and they are discussed out of sequence. For example, the report implies that the pilot entered class C immediately after the clearance was denied and presents it as an airspace infringement, but the altitudes in the other requests suggests that it happened after the pilot read back "not above 1000 feet" i.e. he may have thought he had received a clearance requiring a descent.
Important issues are e.g.
- The planned flight path tracked west of Coffs Harbour through the corner of the 5500 step to the north, and the 3500 and 4500 steps to the south.
- The pilot was at 6500 and contacted ATC and requested clearance to track through the corner of the 5500 step (less than 3 minutes transit time).
- The controller (a trainee under supervision) advised clearance in class C was not available due to workload, and suggested transit through the class D airspace. There were no other aircraft in the Coffs Harbour airspace and no expected IFR arrivals or departures, however "controller performance assessment reports and daily training records included debriefing and coaching comments emphasising to trainees and controllers to be cautious with issuing clearances below A080 through the [Coffs Harbour] airspace" and the supervisor judged denying the clearance was conservative but appropriate.
- The pilot contacted the Class D controller, who asked whether he wanted to remain at 6500. The pilot said yes, so the Class D controller said to contact the class C controller for clearance.
- The pilot switches back to the Class C controller, and meanwhile the class D controller has also advised the Class C controller to expect the call.
- The Class C controller sends the pilot back to the Class D controller again. At this point I imagine the pilot stress levels are rising.
- The Class D controller says that clearance would only be available "not above 1000 feet", but doesn’t provide any tracking instructions.
- It appears that the pilot read back "not above 1000 feet" as if it were a clearance, entered the Class C and began descending. Terrain was about 3000-4000 feet.
- Shortly afterward, the pilot reported that they were OCTA at 4100 in clear conditions, and that they would be requesting clearance through the southern steps when they reached them.
- The Class D controller asked them to report entering controlled airspace.
- After a short climb they continued to descend until they crashed.
A transcript of the actual radio calls would be very helpful. Times are not given for most of the events and they are discussed out of sequence. For example, the report implies that the pilot entered class C immediately after the clearance was denied and presents it as an airspace infringement, but the altitudes in the other requests suggests that it happened after the pilot read back "not above 1000 feet" i.e. he may have thought he had received a clearance requiring a descent.
Important issues are e.g.
- ATC denied clearance due to workload for no obvious reason - there were no other aircraft in the airspace.
- Pilots need to maintain awareness of terrain clearance and not assume that ATC are protecting them even if they have received a clearance or instructions.
- ATC need to be alert for pilots reading back things that are not meant to be clearances or instructions and clarify if necessary.
So basically according to the Coroner, Airservices murdered the pilot and passenger. Judging by what happened to Glen Buckley, CASA murders the industry and judging by the quality of its reports, ATSB murders the truth.
How can anyone consider anything these institutions do as promoting safe aviation? All of these alleged behaviours encourage industry participants into unsafe behaviours.
How can anyone consider anything these institutions do as promoting safe aviation? All of these alleged behaviours encourage industry participants into unsafe behaviours.
My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.
As another recent example, the ATSB report on the Renmark tragedy says:
Well that’s OK then. Nothing more can usefully be done to find the truth. Move on, nothing to see here. Only three dead.
(Perhaps the deceased, including the CASA FOI, were among the critics of CASA identified in Mr Carmody’s ‘research’ as being the kinds of people likely to have accidents. Maybe those involved in the Mangalore tragedy, too...)
ATSB has powers to compel the disclosure of information, and the failure to disclose when compelled to do so is a criminal offence. The only people excused are coroners in their capacity as coroners. Those powers are there precisely to enable ATSB to obtain information when it is not volunteered, and that includes when not volunteered by CASA.
Although the procedure was - according to ATSB - “not necessarily contributory to the accident”, the procedure was - according to ATSB - “inappropriate and, if followed, increased the risk of asymmetric control loss.”
Wouldn’tcha think it might be important to find out whether CASA had insisted on the risk-increasing, folklore-based procedure to be in the operator’s C&T Manual, or whether CASA had overlooked the existence of the risk-increasing, folklore-based procedure in that Manual? If either of those were true, would it not follow that CASA may be part of the problem? And wouldn’tcha think it might be important to make a recommendation - or whatever the weasel word is these days - for CASA to find out whether the risk-increasing, folklore-based procedure is in other T&C Manuals and get the procedure removed?
The “safety issues and management” part of the report focussed on procedures for the safety of CASA personnel! “The [CASA temporary safety instruction’s] intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).” Make CASA FOIs ‘safer’ and the job’s done!
As another recent example, the ATSB report on the Renmark tragedy says:
The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss.
...
Despite the operator’s procedure being approved by the Civil Aviation Safety Authority (CASA), reducing the power to flight idle on a turboprop aircraft is not representative of the drag associated with a real engine failure as it does not take account of the beneficial effect of auto-feather/negative torque sensing systems. Consequently, had flight idle been selected it would have created significantly more drag on the ‘failed’ engine, making it more difficult to control the aircraft and achieve the expected OEI performance. While the operator’s procedure only required use of this power setting during the initial ‘phase one’ checks (which would be expected to be completed in less than 30 seconds), it has been a contributing factor to previous asymmetric loss of control accidents (for example AO-2010-019 in the section titled Related occurrences).
The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.
...
Despite the operator’s procedure being approved by the Civil Aviation Safety Authority (CASA), reducing the power to flight idle on a turboprop aircraft is not representative of the drag associated with a real engine failure as it does not take account of the beneficial effect of auto-feather/negative torque sensing systems. Consequently, had flight idle been selected it would have created significantly more drag on the ‘failed’ engine, making it more difficult to control the aircraft and achieve the expected OEI performance. While the operator’s procedure only required use of this power setting during the initial ‘phase one’ checks (which would be expected to be completed in less than 30 seconds), it has been a contributing factor to previous asymmetric loss of control accidents (for example AO-2010-019 in the section titled Related occurrences).
The ATSB sought information from CASA regarding the circumstances under which the incorrect procedure was approved for use by the operator. Despite this request, no information was provided by CASA. Consequently, the ATSB was unable to determine whether the approval of incorrect information was an isolated human error or symptomatic of a systemic deficiency with the approval process.
(Perhaps the deceased, including the CASA FOI, were among the critics of CASA identified in Mr Carmody’s ‘research’ as being the kinds of people likely to have accidents. Maybe those involved in the Mangalore tragedy, too...)
ATSB has powers to compel the disclosure of information, and the failure to disclose when compelled to do so is a criminal offence. The only people excused are coroners in their capacity as coroners. Those powers are there precisely to enable ATSB to obtain information when it is not volunteered, and that includes when not volunteered by CASA.
Although the procedure was - according to ATSB - “not necessarily contributory to the accident”, the procedure was - according to ATSB - “inappropriate and, if followed, increased the risk of asymmetric control loss.”
Wouldn’tcha think it might be important to find out whether CASA had insisted on the risk-increasing, folklore-based procedure to be in the operator’s C&T Manual, or whether CASA had overlooked the existence of the risk-increasing, folklore-based procedure in that Manual? If either of those were true, would it not follow that CASA may be part of the problem? And wouldn’tcha think it might be important to make a recommendation - or whatever the weasel word is these days - for CASA to find out whether the risk-increasing, folklore-based procedure is in other T&C Manuals and get the procedure removed?
The “safety issues and management” part of the report focussed on procedures for the safety of CASA personnel! “The [CASA temporary safety instruction’s] intent was to generally provide higher risk protection around operations involving CASA flying operations inspectors (FOIs).” Make CASA FOIs ‘safer’ and the job’s done!
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Training notes discouraging issuing clearances below 8000 and a controller whose first instinct in their first week of on the job training is to deny a clearance despite zero traffic in the airspace suggest something rotten at Airservices.
It never ceases to amaze me how people will just read what supports their bias in these accident reports. I am very much of the view that a PIC needs to take that responsibility seriously and plan for contingencies that are within their control, fuel, weather navigation etc. Have another read and note what this PIC did not do that had a significant influence on the sequence of events. Did not have a recent BFR
Did not have any charts or EFB available to at least have some understanding of terrain and most likely did not obtain a weather forecast
ATC contributed in part by not providing a clearance but as it states in the report.the PIC could have taken a route that did not put him in the high ground.
I always challenge the assertion that ATC tell pilots what to do. any pilot who thinks that will come unstuck. I have heard it said that ATC will kill you if you let them. In this accident the PIC was along for the ride just as much as his unfortunate passenger was. The Australian system is far from perfect but it is what it is and to operate in it you have to be up to speed on how it works. Transits through coastal CTZ should not be a rarity but denial of a clearance is always a possibility and should be planned for. The lesson out of this report to pilots is stay current. plan your trip and accept your responsibility as PIC. With the information provided in the report this bloke did none of that and the unfortunate confluence of circumstance lead to his death and that of his passenger. If he had got a clearance through Coffs then maybe the accident would not have happened but with such an attitude to his responsibilities it was possibly only a matter of time before it did.
Based on the available information, the ATSB concluded that the pilot had not met the CASR Part 61 flight review requirements and, as such, did not hold the required licence to undertake the
flight.
flight.
The ATSB also found that the pilot was not carrying suitable navigation equipment and had most likely not obtained the required weather forecasts. These factors reduced the pilot's ability to
manage the flight path changes and identify the high terrain. This led to the aircraft being descended toward the high terrain in visibility conditions below that required for visual flight, resulting in controlled flight into terrain.
manage the flight path changes and identify the high terrain. This led to the aircraft being descended toward the high terrain in visibility conditions below that required for visual flight, resulting in controlled flight into terrain.
While it was the pilot’s decision to descend from 6,500 ft and continue along the direct track instead of other available safe options, this decision was likely influenced by the information provided by the controller
I do wonder if Lead Balloon's obvservation
could perhaps be further explained by the career path involving all 3 organisations of the current ATSB Commissioner.
May be, maybe not!
CC
My view is that Airservices, ATSB and CASA are now effectively running a mutual protection racket. What’s not said in ATSB reports or not followed up by ATSB speaks volumes.
May be, maybe not!
CC
Thread Starter
The text in my letter to Greg Hood of 18 September 2020 is self-explanatory - see below:
I would like to make it very clear, because I was involved at the time, that the only reason for the Minister’s directive was to prevent accidents such as the Mooney crash west of Coffs Harbour.
It is simply unconscionable that the ATSB does not mention this.
Dear Greg
Further to my letter of 16 March 2020 regarding the fatal Mooney crash on 20 September 2019, I trust that your report will make it absolutely clear that the reason for the attached direction for Airservices to put in an approach radar facility at places like Coffs Harbour was to move away from the “road block” airspace.
As shown in the attached letter, a previous consultant to the CAA, Mr Tony Broderick (the ex-FAA Flight Standards Deputy Associate Administrator and head of the Regulation and Certification Complex) had made it absolutely clear that Class C could not be operated safely without an approach radar facility.
I explained that the way we did it in Australia was simply to deny a clearance to the VFR aircraft, with the associated safety implications.
This appears to be what happened in the case of the Mooney accident.
Please make sure these important points are covered, as well as the fact that Airservices has not complied with the direction.
Best regards
Dick Smith
Further to my letter of 16 March 2020 regarding the fatal Mooney crash on 20 September 2019, I trust that your report will make it absolutely clear that the reason for the attached direction for Airservices to put in an approach radar facility at places like Coffs Harbour was to move away from the “road block” airspace.
As shown in the attached letter, a previous consultant to the CAA, Mr Tony Broderick (the ex-FAA Flight Standards Deputy Associate Administrator and head of the Regulation and Certification Complex) had made it absolutely clear that Class C could not be operated safely without an approach radar facility.
I explained that the way we did it in Australia was simply to deny a clearance to the VFR aircraft, with the associated safety implications.
This appears to be what happened in the case of the Mooney accident.
Please make sure these important points are covered, as well as the fact that Airservices has not complied with the direction.
Best regards
Dick Smith
It is simply unconscionable that the ATSB does not mention this.
a previous consultant to the CAA, Mr Tony Broderick (the ex-FAA Flight Standards Deputy Associate Administrator and head of the Regulation and Certification Complex) had made it absolutely clear that Class C could not be operated safely without an approach radar facility.
As always, it's about money. A radar approach service at towered airports costs. Stop making AsA "make" money for it's owners and we might get a better service.
Thread Starter
Lookleft, you state in your post:
Lookleft, why should they be planned for? Surely you agree that if Airservices had changed the airspace back to Class E, as they had planned to do, and as mentioned in the ATSB report, the pilot and his passenger would most likely be alive today.
If you are suggesting that pilots flying over Class D airspace should do all their planning on the possibility that they may not get a clearance, that is something that would only be required uniquely in Australia. Surely we should follow world’s best practice.
Transit through coastal CTZ should not be a rarity but denial of a clearance is always a possibility and should be planned for.
If you are suggesting that pilots flying over Class D airspace should do all their planning on the possibility that they may not get a clearance, that is something that would only be required uniquely in Australia. Surely we should follow world’s best practice.
Dick what are your thoughts on a pilot who did not do the legally required BFR? Could you please comment on what you think should be done about pilots who do not do any flight planning or even obtain a weather forecast before they operate? Do you agree that pilots should always plan contingencies for any flight they conduct or that a single plan of action will do? When you flew around the world in a helicopter did you blindly follow what ATC told you to do or did you have a contingency plan/ In this instance ATC definitely influenced the sequence of events but this pilot should not have been flying with their haphazard attitude to flying. Especially in a relatively high performance single such as the Mooney.
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I do think Dick has a strong point here, and Airservices do provide a substandard ATC service compared to the US. Some controllers seem to get flustered anytime there is more than a couple of non RPT aircraft in their sector. Only have to look at how restrictive they have been with ILS training in the Melbourne basin over the years. They forget when denying clearances in the modern age we can now see all the same traffic (or more likely lack of) ADS-B returns on our iPads as they see when assessing the traffic load and deciding whether to fit a GA aircraft into the flow or not.
Without doubt the back and forth between the class D & C controllers and the ultimate refusal of the clearance was a contributing factor to the accident (especially with no IFR arrivals or departures at Coffs Harbour at the time). However the pilot only needed to get a forecast including a sat pic and plan his flight coastal seeking a not above clearance/transit through Coffs’ class D to have ensured a totally different outcome. Perhaps filing a flight plan may have also helped with more efficient handling by ATC as well. Very “relaxed” attitude to airmanship by the PIC to put it mildly.
Without doubt the back and forth between the class D & C controllers and the ultimate refusal of the clearance was a contributing factor to the accident (especially with no IFR arrivals or departures at Coffs Harbour at the time). However the pilot only needed to get a forecast including a sat pic and plan his flight coastal seeking a not above clearance/transit through Coffs’ class D to have ensured a totally different outcome. Perhaps filing a flight plan may have also helped with more efficient handling by ATC as well. Very “relaxed” attitude to airmanship by the PIC to put it mildly.
Thread Starter
Here is an article from Sydney’s Daily Telegraph headed “Lack of training, GPS behind fatal plane crash.” Notice how the article makes no mention of ATC involvement and the denial of a clearance. It also omits that Airservices had not complied with the safety directive to provide an approach radar facility where Class C above Class D was in use.
Notice that it puts all the blame on the pilot and mentions that the pilot had started to descend near high terrain, without suggesting in any way that a clearance had been refused at the obviously safer level for terrain clearance of 6,500 feet
Notice that it puts all the blame on the pilot and mentions that the pilot had started to descend near high terrain, without suggesting in any way that a clearance had been refused at the obviously safer level for terrain clearance of 6,500 feet
Last edited by Dick Smith; 20th Jan 2021 at 03:08.
Thread Starter
Lookleft, I agree with the drift of your approach and it is clear that the ATSB has made important observations.
However that doesn’t explain why they have decided to leave out the fact that Airservices had been given a directive by the Minister – which if complied with, would have resulted in the airpace being Class E, or an approach radar facility being provided.
In each case, there is less likelihood that the plane would have crashed with the loss of the lives of two people.
However that doesn’t explain why they have decided to leave out the fact that Airservices had been given a directive by the Minister – which if complied with, would have resulted in the airpace being Class E, or an approach radar facility being provided.
In each case, there is less likelihood that the plane would have crashed with the loss of the lives of two people.
I agree that an approach radar at all Class C airports is the safer way to go and I don't disagree that there is less likelihood of this accident occurring if one had been available. If a radar is not available however don't plan or make decisions based on the desire that one should be available. The lack of a radar and a clearance exacerbated the poor airmanship, it didn't cause it.
Some controllers seem to get flustered anytime there is more than a couple of non RPT aircraft in their sector. They forget when denying clearances in the modern age we can now see all the same traffic (or more likely lack of) ADS-B returns on our iPads as they see when assessing the traffic load and deciding whether to fit a GA aircraft into the flow or not.
When denied a clearance I usually reply and suggest that I can take any altitude of their choice including vectoring. The response usually includes a level of spite that subconsciously suggests how dare I ask again when I’ve already been told no.
I often don’t care if I have to go 30 miles or more out of the way if it means I can avoid some terrible turbulence and near scud-running at the legal minimum altitude over built-up areas.
Perhaps it would be good practice for these pilots flying as students of the blue tail to be denied a clearance on occasion so they can actually learn how to read a map and navigate around Melbourne and learn properly, rather than being guided and babied through airspace by ATC.
Edit: it has occurred to me that those IFR students are paying for the service and as a VFR I am not. I’ve often wondered if that is a factor in all this.