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Partenavia fatal crash Wagga 1998. 17 defects present

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Partenavia fatal crash Wagga 1998. 17 defects present

Old 28th Jun 2020, 14:03
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Partenavia fatal crash Wagga 1998. 17 defects present

It will be 22 years next month 20 July 1998, that Partenavia VH-IXH crashed into a hill during a DME Arrival into Wagga, killing the pilot and his passenger. The BASIS report stated: The pilot was operating the aircraft in IMC below the approved MDA and that low cloud was covering Gregadoo Hill (the site of the accident) at the time of the accident.. The pilot had been a flying instructor in his previous job and flying the Partenavia on charter work was his first job after being an instructor

The BASIS report: https://www.atsb.gov.au/publications...aair199802757/

An inquest was later held at Wagga. Evidence was presented that the pilot had kept a hand-written list of defects relating to the aircraft. The BASIS report stated the aircraft’s maintenance release was valid at the time of the accident and no entries had been made in relation to outstanding un-serviceable items. It was reported that the pilot would inform the chief pilot of any maintenance action required and that would be coordinated with the maintenance organisation. The aircraft maintenance records contained no outstanding airworthiness issues.

The investigation team was provided with the hand-written note compiled by the pilot, which listed aircraft defects. The list was to be supplied to the aircraft operator and maintenance organisation for the next period of scheduled maintenance and identified items that the pilot considered could require attention. The BASIS team assessed the significance of the list and recovered some components from the accident site for more detailed examination. However, no evidence was available to suggest that the listed items had contributed to the circumstances of the occurrence.

The aircraft was equipped with a GPS satellite receiver and the pilot broadcast his intention to conduct the Albury-Wagga GPS Arrival. A ground based navigation aid provided azimuth guidance to the pilot.

At the inquest, the partner of the pilot gave evidence that the pilot had requested the list of defects on the hand-written note was to be given to investigators in event of an accident. The partner stated the pilot had frequently expressed his doubts concerning the state of airworthiness of the aircraft. In addition, he held concerns the security of his job would be compromised if he had recorded these defects in the maintenance release.

Following the accident, the partner of the pilot had given the hand-written list of defects to a BASIS inspector who expressed to the partner that as the aircraft was 25 years old, these sort of defects can be expected.

The following items were on the hand-written list and were un-rectified at the time of the accident.

1. Pilot’s left seat loose on rails and rocks fore and aft in flight

2. Brakes weak

3. Severe nose-wheel shimmy

4. ADF intermittently inoperative

5. Autopilot inoperative

6. Landing light inoperative

7.Cockpit panel lights inoperative.

8. Standby artificial horizon inoperative

9. Standby altimeter inoperative

10. No. 1 VHF Com aerial broken.

11. No. 2 Comm/Nav inoperative

12. Transponder inoperative (12 months)

13. Left engine oil pressure low light illuminated at all times

14. Left engine CHT low indication.

15. Nose-wheel oleo leaking oil

16. Rudder Trim very stiff to move

17. No shoulder harness installed

The inquest was told that many of these defects had been outstanding for several months despite passing the 100 hourly inspection.

Note: The writer was present at each day of the Inquest

"



Judd is offline  
Old 29th Jun 2020, 02:26
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Unhappy This is very relevant today

I may or may not know of a few IFR/VFR charter operators where this level of unserviceability is rife throughout their fleet...but the MR's are clean as a whistle.

I have heard these days that during CASA inspections or audits, companies are questioned on why a 40 year old clapped out 210/207/Chieftain or what have you, has a practically untouched MR. You only have to look at these things from the outside to know a defect list (most likely including but not limited do the 17 listed in this traigic P68 accident) should exist on the MR.

Pilots... and LAMEs.... are all too often between a rock and a hard place from the pressures of management to doing the professional & safe thing.

I guarantee that even today, ESPECIALLY in this current economic environment, pilots feel under the pump or in a position of low bargaining power because "If I endorse this MR, i'll be in the bad books and the I won't that twin upgrade" or "my employer will sack me on the next chance he gets, and I'll never find another job".

What really resonates with me about this accident is that I do know pilots of all skill levels keep diaries or send notes to the partners/loved ones for the "Just In Case" flights. All in the hope that CASA & the ATSB will use it in a way that pilots and future professionals alike will never spill blood over $h*t like this again.


Off topic scary thought: The notion that business owners are also operating as a HAAMC or the principal LAME fixing their own fleet. They might be one of the best engineers in the industry, thats great! But genuine Textron parts are by no means cheap. If your the one signing off an aircraft while also having to fork out cash for a new cylinder/cable/fuel valve or spar replacement, isn't their some conflic of intrest? ...Some laws need to be re-written.










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Old 29th Jun 2020, 03:08
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It's amazing how some aircraft can fly 99 hours out of 100 without a single defect, but then accumulate 20 defects in that final hour before going in to maintenance. I guess some aircraft are just scared of hangars........

As an engineer pointed out to me, if there is nothing written on the maintenance release they can't justify investigating or rectifying any non-existent faults, and nor can they "discover" things that are only apparent when the aircraft is in flight. They also can't justify the extra man hours chasing defects that are "rumoured" to exist.
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Old 29th Jun 2020, 04:57
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Following the accident, the partner of the pilot had given the hand-written list of defects to a BASIS inspector who expressed to the partner that as the aircraft was 25 years old, these sort of defects can be expected.

The BASIS inspector was probably right. There would be hundreds of general aviation aircraft around Australia and currently flying that would be 25 years old or more. Based on the logic expressed by the BASIS inspector there would be hundreds of maintenance releases with numerous defects logged but with the aircraft still flying. .

More likely of course, those maintenance releases remain squeaky clean - just like the maintenance release of Partenavia VH-IXH before the aircraft hit Gregadoo Hill.

I recall an LAME being concerned about a damaged nose-wheel of a Partenavia brought into his hangar with every indication it had sustained the damage during a landing but not recorded in the maintenance release. When questioned if he thought CASA should be involved he agreed adding he would lose future work if it got around he had contacted CASA. Needless to say he failed to contact CASA despite the substantial damage to the nose wheel.

Last edited by sheppey; 29th Jun 2020 at 05:11.
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Old 29th Jun 2020, 05:50
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The partner stated the pilot had frequently expressed his doubts concerning the state of airworthiness of the aircraft. In addition, he held concerns the security of his job would be compromised if he had recorded these defects in the maintenance release.
There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.
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Old 29th Jun 2020, 09:56
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The chronic under-recording of defects on MRs is partly attributable to the persistent folklore that any and all defects entered on an MR result in the aircraft being ‘grounded’. But only partly. In the case of Partenavia VH-IXH the MR should have been endorsed: “Deathtrap”.

Then there’s the chronic problem of pilots who either don’t read or don’t understand an MR anyway.

Some pilots deserve the nickname “Deathwish”. Pity the poor bastards who are/were their passengers.

That’s a few decades and a few hundred millions in regulatory ‘reform’ for ya!
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Old 29th Jun 2020, 10:05
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Originally Posted by neville_nobody View Post
There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.
Inhave to agree Nev. This is a well known issue within GA and pilots/engineers are their worst own enemies!
This will never change, not till the very last plane is either crashed or taken to the bone yard!

Last edited by machtuk; 29th Jun 2020 at 23:21.
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Old 29th Jun 2020, 10:23
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Originally Posted by neville_nobody View Post
There's the problem right there. Nothing will ever change until that changes. Bit like the whole problem they're having in the Law at the moment. Noone wants to speak up because they might as well quit the industry before they even start. This Pilot had 1000 TT/ 279 ME PIC so the twin time would have been like gold in the logbook.
too right. I worked with Sam at the flying school where he was before this. I remember being extremely envious that he’d got the IFR twin charter gig. That school was a mess for various reasons (overseas cadets being promised a career based on the size of the parents’ wallets, not children’s skills). Any road out of that rut was paved with gold. This was the late 90s after all. “Whaddaya mean you’ve only got 2800 hours, this is a turbocharged twin!”

You were lucky to have any job. The balance between silence vs speaking up and never making it aviation was a fine line.

It may not have caused the crash (but may have been a factor through distraction or fatigue) but I can totally sympathise with his reluctant acceptance of those faults at the time.
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Old 29th Jun 2020, 11:12
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I may or may not have worked somewhere where the CP said the only thing that can be written up without his approval is a taxi or landing light. (But not both). He also didn’t like being challenged as to why he thought a “gripe sheet” was better. One of those guys who bangs on about safety reports for everything. So I may or may not have put a safety report in about being told not to write stuff up. Weird bloody coincidence but next roster had no twin flying on it.
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Old 29th Jun 2020, 13:26
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In another era I knew a DCA Examiner of Airmen (GA) based at Moorabbin. A former Army pilot, his advice was sought by many a young pilot starting out on his flying career. In those days Examiners were allotted 50 (?) hours a year personal practice, paid for by DCA. There was no shortage of flying schools at Moorabbin to choose from.

It didn't take long for the word to get around that he had no qualms about writing up a snag in the maintenance release where warranted. He would ring up various flying schools to make a booking only to be told by amazing coincidence all the aircraft were booked out. There was nothing he could do about it. He eventually took early retirement in disgust sickened by what he had seen.

Just think. if that sort of treatment could happen to a respected Examiner, what chance is there for the average GA pilot who needs to earn a crust?

Further to the subject of the Partenavia crash at Wagga. I did some of the pilot's instrument rating training prior to him moving to Wagga. He flew very well then. I warned him that out of the camaraderie of the flying school where he was a flying instructor, the world would be different as a charter pilot. That there would be subtle and not so subtle pressures to break the rules. That it would be up to his own strength of character to draw his own line in the sand. It has ever been thus in general aviation.

Last edited by Centaurus; 29th Jun 2020 at 13:50.
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Old 30th Jun 2020, 03:53
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I was a bank run pilot in the late nineties, by coincidence based out of Wagga at the time of the accident. As Compressor Stall says, finding (& keeping) a twin job in those days was tough, so I empathise deeply with the commercial environment the poor guy found himself in.
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Old 30th Jun 2020, 05:01
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Found and wrote up a defect in a jump plane. ... Corrosion pin hole in fuel line under the floor beneath the seat.
A/c had been flown in this condition for weeks by others and had red stains under the belly.. Found by chance as when replacing the floor hole cover . something moving reflected the light. Que.? Was the needle thin shoot of fuel hitting the floor side tin.... adding to a small puddle, Curiosity saved the cat.
It was the owner that blew up, (for the MR entry), fortunately not the aircraft.
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