Mooney accident pilot refused a clearance at 6,500'

[Capn Bloggs]

The controllers are copping some flak here because there was no traffic. What about the scenario where there was a conflicting aircraft on descent into Coffs? As others have said, you've got to be ready for the worst.

Originally Posted by Sunfish

What happens when the non rpt pilot population perhaps one day decides that the regulations are a joke, enforcement is a joke, AsA is a joke and the ATSB is a joke?

Precisely what VFR in Class E is all about. Just go and do your own thing, don't concern yourself with anybody else. They will (probably) keep out of your way.

[Ixixly]

Originally Posted by le Pingouin

The controller was an early phase trainee so it's hard to label it a systemic issue. "Workload" is a somewhat personal perception - he may have been preoccupied with thinking of other issues he perceived to be more important, got flustered & chose the easy solution of denying a clearance. Was there any indication to the controller that this course of action would be in any way dangerous? I very much doubt it. Trainees in any field often choose less than optimal solutions, provide a less than ideal service & just plain screw up, it's all part of the learning process. The instructor probably saw it as a minor inconvenience for the pilot that wasn't unsafe so didn't intervene - to be discussed later.

Why didn't the pilot simply deviate around the airspace? He'd deviate around weather so why is this any different? Or would that have presented a problem for this pilot as well?

P.S. it was "C" the pilot was denied the clearance for.

What was it during his training that made him decide that it would be better to take the easy way out and deny the clearance though? Nothing takes away from the Pilots responsibility in this but I don't believe there is anything that can be changed to Pilots training syllabus or requirements, in general, to address this issue unless we're going to start denying Licences based on perceived "Poor Attitude" either during their training or AFR, even then clearly this person wasn't able to legally fly and chose to, as such no real changes there I think would have affected that part of the flight at all.

This is the problem in these discussions, we're so focused on the minutiae instead of actually discussing the relevant parts that could be fixed for the future. In this case, the Pilot is dead, we can't pick his brains to figure out exactly why he chose to make the decisions that he did and I don't believe any changes to regulations would prevent this from happening. What we do have are the Controllers who were on that day and whose brains we can pick to see why they made their decision and what can be done in the future to enable them to make different decisions and instead all we're getting is "Workload", I don't think this is good enough. This isn't about just one incident either, I'm sure we've all been in situations where clearance was denied with 0 traffic around and no particular reason that we can see, but the thing is there HAS to be a reason why, was there something else happening in the background? Was that controller overloaded with other sectors? Did they just decide not to because they didn't have to and decided that was good enough? I think the fact that a lot of Pilots don't really trust the ATC system in this regard means that the trust is very reduced and more needs to be done to at some level to restore that. Flight Instructors, ASA Instructors, Controllers, Pilots, Ground Handlers, CASA and everyone else involved in Aviation are part of the safety net from start to finish, when there is an incident there isn't always much that can be done and focusing on the things that can't be fixed doesn't help anyone at all.

[jonkster]

Originally Posted by Sunfish

Am I right in thinking that a pilot cleared through airspace at a thousand feet would assume that such a flight path at that level was safe? If it wasn’t, what is the point of having ATC if you are not RPT heavy iron?

I assume it would have been safe if he was there, he never got into that airspace, he was in G airspace, he descended into what I am assuming must have been IMC and unaware of what was outside, into the ground well before he got to the airspace.

You are responsible for maintaining VMC in G, in this case, while in G he flew into cloud.

The pilot may have been mentally overloaded or unsure of procedures which is tragic and if there may be systems/procedures we can put into place to reduce the chance of such problems leading to catastrophe, (should a pilot be overloaded and out of their depth), they should be investigated but we are supposed to be trained and operate to a standard where flying VFR, we do not deliberately enter IMC.

Would you fly into cloud to make the requirements for an upcoming clearance? Surely you wouldn't. This pilot did. The failure to get his requested clearance was a factor but similar things happen daily without it leading to catastrophe because pilots take appropriate courses of action to work around it. This pilot didn't. Why? We cannot know for certain, and while I think ATC actions were factors the pilot's choice to proceed into IMC was a major factor.

Saying he must have felt he had to do it to comply with ATC even if it meant descending into cloud seems like a problem more at the pilot's end of the spectrum rather than ATCs, to me. That may include his training or perhaps his age/cognitive state.

[le Pingouin]

Ixixly, how about training pilots to always have a plan B?

Controllers are trained to say "no" as part of ensuring workload remains manageable, it's part of the job because if the workload exceeds your ability to handle you're no longer in control. You don't just say "yes" without considering the consequences - a random unannounced flight presents a challenge because you need to work out where they are & how you'll separate. You don't just make it up as you go along but continually plan.

There will always be situations where a controller will say "no", there is no way of avoiding that. As I mentioned, airspace is just another obstacle to be avoided if a clearance is denied, no different to weather or terrain, so treat it as such.

[Squawk7700]

This is what I had been thinking after reading the report again:

- The pilot was tracking from Murwillumbah to Taree and for the most part, the track was exactly that.
- The fact that he asked for a clearance to enter Class C was merely as he was going to pass through a small chunk of airspace and it would have been convenient.
- He gets bounced around and annoyed with ATC so comes up with another plan.
- He reports as ‘currently 4100 in clear and we’re OCTA' as you would expect with an update as he exited their airspace to do his own thing.
- He climbs back to 4,500ft for 5-6 minutes to remain hemispherically correct.
- Based on the track, he clearly has no intention of entering Class-D at 1,000ft or below as he'd have to turn 45 degrees left, a long way off track and may be over solid cloud at this time. Why would you, as he can't get down?
- He recalls that the cloud base is 2000-3000ft after witnessing it out of Murwillumbah.
("At the time of the incident the region was covered in widespread broken low cloud. With bases generally between 2000 - 3000ft above mean sea level")
- He checks the GPS and looks ahead knowing that past Mount Moombil area, that the terrain is very low and will likely be well clear of cloud.
- A controlled descent begins through cloud. ("The descent rate averaged about 850 ft per minute with a groundspeed between 165 kt and 175 kt") - this does not sound like an out-of-control descent as testified by the previous owner of the aircraft.
- Impact at 2,900ft.
- Had the descent begun only a couple of miles later, he would have missed the mountain completely and been in clear skies at 2000-3000ft.


BUT..... then I looked on the map and realised that he still had 90 nautical miles remaining!
Once I realised that, his actions made no sense, except for if he believed that the cloud ahead was worse than what he was currently experiencing and he needed to be under it.

The rest of his actions aside from the descent all made perfect sense and when you look at the airspace versus his track, then you can hardly blame ATC for such a tiny part of a bigger picture.

[andrewr]

Based on the track, he clearly has no intention of entering Class-D at 1,000ft or below as he'd have to turn 45 degrees left, a long way off track and may be over solid cloud at this time.

He has Class D in the step ahead of him. I suspect the GPS didn't give an easy indication of the exact altitudes of the steps, just that they were there.
I think the Class D in front of him, on track was what he thought he had been told to transit at or below 1000'.

[junior.VH-LFA]

A “clearance to descend” (if that’s how it was interpreted) does not imply that the pilot was allowed to descend below 1000ft in IMC in a VFR aircraft.

There seems to be two mindsets commenting in this thread:

a) those that think the clearance (or lack of) was a contributing factor
b) those that know that want to blame Airservices regardless of any other information that’s put infront of them.

[Squawk7700]

Originally Posted by andrewr

He has Class D in the step ahead of him. I suspect the GPS didn't give an easy indication of the exact altitudes of the steps, just that they were there.
I think the Class D in front of him, on track was what he thought he had been told to transit at or below 1000'.

He appears to be lined up with the 3,500ft step with Mt Gladstone at 2,504ft and 1,200ft+ terrain after that, so it seems incomprehensible that he would think he needed to be below 1,000ft and make it through. He only needed to be around 10nm right of track to avoid all of this hassle and stay up there for the next 80 miles and into clear skies. By the time he got there (to the class D) he would have been in 10k+ vis and would have realised it couldn’t be done.

Also, the Class C clearance was denied for the northern sectors, but what about the southern sectors... where is the transcript ASA and what was actually said, not a vetted summary?

If he was descending in cloud in an attempt to get to 1,000ft in order to comply with a direction from ATC some 90 miles from the destination, it simply doesn’t compute.

I feel like he’s gone on his own with his own descent to avoid CTA completely. It’s not uncommon, especially when you get multiple knock-backs.

[VH-MLE]

Post #190 by Lookleft sums it up well in my opinion.

Having read the report, it seems fairly clear the PIC demonstrated a poor attitude to his role as PIC. This attitude not only claimed his life, but that of his son too. The view that a lack of a clearance being available was a significant factor in this accident is ridiculous. I'm no fan of AirServices, however it's not their role to fly the aircraft - that's the PIC's job!

There's a well documented list of hazardous attitudes (on pilot decision making) & this pilot seems to have had at least one or more of them.

[TwoFiftyBelowTen]

I wonder if the tower meant to be proposing 1,000 ft coastal. I wonder if that crucial word was missed.. or missing?

[McLimit]

What about the scenario where there was a conflicting aircraft on descent into Coffs? As others have said, you've got to be ready for the worst.

Inbound IFR aircraft do not just 'pop up.' That's not how an ATC system works. They are known about well in advance through co-ordination from the previous controller. The Tower also gets a departure message from the AFTN network.

There is a culture of 'clearance not available' to VFR aircraft in Australian ATC. It's ingrained from day one of ATC training.

[Dick Smith]

I have written to the ATSB requesting they make available the full transcript.

In the interests of transparency and safety they should not keep it secret.

I wonder if the controller has other class G workload that has not been mentioned in the report?

[Capn Bloggs]

Dick, good for you. I too asked for the actual calls made during an incident that was published a few years ago. After a bit of tooing and froing, I was eventually ignored. Not good enough.

[On eyre]

Originally Posted by VH-MLE

Post #190 by Lookleft sums it up well in my opinion.

Having read the report, it seems fairly clear the PIC demonstrated a poor attitude to his role as PIC. This attitude not only claimed his life, but that of his son too. The view that a lack of a clearance being available was a significant factor in this accident is ridiculous. I'm no fan of AirServices, however it's not their role to fly the aircraft - that's the PIC's job!

There's a well documented list of hazardous attitudes (on pilot decision making) & this pilot seems to have had at least one or more of them.

What he said exactly.

[Ironpot]

Originally Posted by ausatc123

If a vfr aircraft comes through my airspace below 3000ft, they will drop off radar at certain points and I cannot seperate IFR aircraft inbound or outbound. No approaches for at least minutes 10-15 minutes... If I don't have Arrivals I give the clearance away. If I do I won't. Or should I let every big smasher through and hold 3 jets? How much delay would you feel happy with? A few hundred people for 15 minutes or the vfr takes the long way around four an extra 10 minutes of flight time?

If he had filed a VFR flightplan, would that have helped ?
I envisage ATC would have had an indication of his intentions much earlier and had a heads-up.
What difference if any would flight following have made?

[Arm out the window]

AIP ENR says that VFR flights intending to operate in CTA must submit flight details, with the preferred order of doing that being via NAIPS, then in writing, then by phone, and last by radio. It also says you should submit details at least 30 minutes before you expect to enter controlled airspace, and that 'Flight details submitted with less than the 30 minutes notification may be subject to delay.' Some places won't even let you in as a matter of course if you haven't submitted a plan.

If you don't customarily put plans in then using NAIPS can be a confusing and slow process, but once you get used to it, it's a doddle and just takes a minute or two to put a VFR plan in. You can choose whether you want to do that or not, but it's very probably going to make your life easier.

[Lead Balloon]

One of the more eye-opening experiences I've had over the decades was going for a jolly with an ATCer, in and and out of a capital city CTR, in his lighty. He was a friend of a friend and I wanted to hire his aircraft for a trip.

Amazing how flexible the system was for a call sign whose owner was known by the folks behind the Airservices mics. Simply amazing...

After that, I did a lot more submission of departure and inbound details by radio, and continue to do so, when that's convenient to me. I take the - perhaps naively quaint - view that a government organisation with "service" in its name and sends bills should give me the same level of service as one of its employees in the same operational circumstances.

"Some places won't even let you in as a matter of course if you haven't submitted a plan." Which just goes to show, and has become evident to me over the decades, that differences of outcome in like circumstances are sometimes the result of the personalities, pet peeves and local normalised deviations of those in the system.

Someone usually pipes up and says the people concerned could have been coordinating with other sectors or dealing with other aircraft with plan in the system or dealing with a bee-sting or heart attack, and that apparent different treatment in like circumstances is because the circumstances were actually different. Great: Let's hear what the differences actually were. I do not want to know what the Controller/s involved could have been doing; I want to know what they were actually doing, and why the clearance was actually unavailable. Two sentences.

The Mooney pilot in this tragedy did some stuff that I have never done and, touch wood, would hopefully not choose to do in the future. But, has already been pointed out, there's no explanation of the "why" the requested clearance into C was refused. That simply invites negative speculation about the ATC system and ATSB's motivations.

The failure to make the raw recordings of comms in ATSB reports is, in my view, inexecusable and, again, merely invites speculation about ATSB's motivations.

ATSB - like some in this thread - have no concern about throwing pilots under the bus. One wonders how the ANSP and regulator have reached operational perfection, when they are chronically dysfunctional organisations from a human resources management perspective.

[andrewr]

I want to know what they were actually doing, and why the clearance was actually unavailable.

That is one thing that is actually in the report:

At the time of the Class C clearance request, there was no other traffic below 10,000 ft in the Coffs Harbour airspace, nor were there any impending arrivals or departures during the time the aircraft would have transited the airspace. Within the remaining airspace being managed by the trainee and OJTI, there were five other aircraft being provided an air traffic service. Additionally, in the minute prior to receiving the request from VH-DJU, the trainee had completed handling a flight following request from a VFR aircraft.

[Lead Balloon]

Your reading skills are evidently better than mine, andrew. That's just the what they were doing, not why doing that prevented the grant of the clearance.

[andrewr]

There is more

the trainee assessed that workload and priorities would not permit a clearance at the requested level
...
The OJTI assessed that the workload at the time of the clearance request was low, but the trainee being new to the role may have perceived the workload as higher. The OJTI also stated that while the trainee’s decision was conservative, it was appropriate
...
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

One thing that I find interesting is that a trainee in their first week would be so quick to deny a clearance to a VFR aircraft. And it obviously did not come as a suggestion from the supervisor. They are being trained to deny VFR clearances.