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Coroner not happy with ATSB

Old 30th Aug 2022, 02:14
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The coroner is looking at the cause of death. The ATSB is looking at the cause of the accident. Different perspectives of the same event so for the coroner to criticize the ATSB report for issues not directly involved at the time of impact suggest a fundamental misunderstanding of what aviation investigations are for. BTW Mr/Ms Coroner, ATSB reports never have the IIC name on it.
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Old 30th Aug 2022, 06:22
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The coroner is inquiring into the nature of the death, how they died and factors that led to that. It's not just about 'cause of death', cause of death would be directly related to the impact sequence. How the person came to be in that situation asks a few more questions and does intermix with the ATSB accident report. A few items in the ATSB report seemed to imply there was contributing factors beyond the pilot flying into IMC inadvertently such as possible commercial pressure to 'have a go' and so on, which could have had Worksafe implications and such. The ATSB report does diverge from the accident investigation into a more general investigation into the company and CASAs handling of the company, which is where the Coroner has picked points on about what it has to do with the accident in question.
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Old 30th Aug 2022, 06:27
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The ATSB report does diverge from the accident investigation into a more general investigation into the company and CASAs handling of the company, which is where the Coroner has picked points on about what it has to do with the accident in question.
Its called Organisational factors. The ATSB and others have been looking at such things for a very long time. The Chieftain accident at Young was one of the first accidents that looked beyond the immediate impact of plane against planet. I don't expect a coroner to include that but they shouldn't be criticizing the ATSB for doing so. LB can clarify the role of the Coroner as to whether they look at the "nature" of the death or the cause of death. IMHO a significant difference in meaning.
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Old 30th Aug 2022, 06:31
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If you read the coroners report it outlines what he is looking at with reference to the coroners act. His comments WRT the ATSB is more about the evidence the ATSB had to make such accusations, more so the lack of any evidence provided regarding such things. Cause of death is straight forward what killed the person, from a medical point of view.

In short the ATSB made a statement to the effect that Par Avion "encouraged" pilots to depart in marginal weather conditions. This would have peaked the Coroners interest given the lack of evidence provided as it becomes an accusation of possible workplace issues, that is, was the pilot in that location due to being pushed beyond their will by their employer. The other issue identified was the lack of operational information given to pilots, however the coroner suggested that the pilot was reasonably familiar with the route so the lack of printed material was not relevant.

I'm well aware of what organisational factors are, but it muddies the waters in an 'accident' investigation. Possibly it should have been investigated separately.

Last edited by 43Inches; 30th Aug 2022 at 06:46.
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Old 30th Aug 2022, 23:09
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In short the ATSB made a statement to the effect that Par Avion "encouraged" pilots to depart in marginal weather conditions. This would have peaked the Coroners interest given the lack of evidence provided as it becomes an accusation of possible workplace issues, that is, was the pilot in that location due to being pushed beyond their will by their employer.
Wrong. This is what the report actually stated:
In this case, if the weather was suitable at Cambridge, the operator’s pilots were strongly encouraged to depart to assess the weather in-flight, even if the forecast indicated they might not be able to get through. However, the pilots reported having a different understanding of how far to continue with the direct route through the portals when deteriorating weather conditions were encountered and what the decision points were.

This was evident from the pilot interviews and the ATSB’s analysis of the Spidertracks data for the south-west flights, where approaching the portals, some flights diverted down the valleys and tracked to the coast (including the accident pilot 1 month earlier), while others tracked over Federation Peak.
The evidence comes from pilot interviews none of which are going to be made public. It is also quite clear that it comes under the heading of increasing risk and was not a contributing factor. The purpose of an ATSB report is to investigate an accident so that others may possibly learn from it and avoid doing something similar. The coroner in this case does not seem to understand that.

I'm well aware of what organisational factors are, but it muddies the waters in an 'accident' investigation. Possibly it should have been investigated separately.
Then you don't understand the purpose of an ATSB investigation either. Its all part of the investigation. To suggest that an investigation of organisational issues should be separate from the accident investigation is ridiculous. The ATSB are criticized for taking too long as it is let alone having to produce two reports for the one occurrence.
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Old 31st Aug 2022, 01:23
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I suggest you read the coroners report in full and if you have any further questions as to why he came to those conclusions contact him directly. I'm not him or his proxy i'm just parroting what is contained in the report.
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Old 31st Aug 2022, 01:28
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From section 28 of the Tasmanian Coroners Act:

(1) A coroner investigating a death must find, if possible

(a) the identity of the deceased; and

(b) how death occurred; and

(c) the cause of death; and

(d) when and where death occurred; and



(2) A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate.

(3) A coroner may comment on any matter connected with the death including public health or safety or the administration of justice.

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Old 31st Aug 2022, 01:40
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Thanks LB. They must find the cause of death. They may comment.....
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Old 31st Aug 2022, 02:21
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I would have thought that this entails the coroner digging a bit deeper than the collision with terrain:
A coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate
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Old 31st Aug 2022, 03:53
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In Para 86 he makes it quite clear that there was nothing that happened that could be prevented into the future therefore meeting his obligations under Part 2 of Section 28. IMHO there is more to the coroner's objection to the ATSB report than meets the eye. The coroner was basically saying that it was all an unfortunate accident (which it was) and that the pilot's employer had no role in what happened. The ATSB were simply stating that there could be improvements made to the companies SMS beyond just relying on incident reports. They were not blaming the company for anything. I remember after the Mt Hotham report that the Chief Pilot engaged the services of a high profile lawyer to trash that report. In an unusual step the ATSB released a supplementary report which provided even more information about what the accident pilot had done that day. The high profile lawyer didn't have a lot to say after that. I am not alleging anything about why the coroner felt the need to trash the ATSB report but it says more on what improvements could be made to improve the safety of operations to that part of Tasmania than the coroner does.
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Old 1st Sep 2022, 10:59
  #31 (permalink)  
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.. and another pertinent video of perhaps what not to do ....

If you're scud-running, don't follow rising terrain.

In addition to the video in post #1, do have a reflect on the story in the video at post #48 in the same thread. If the final few seconds of the clip, post flight, don't have you involuntarily sucking air in through your teeth, then you are cooler and more collected than most of us, I would opine ....
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Old 1st Sep 2022, 13:31
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That video really shows how quickly it can go from "I can see enough" to "Crap I cant see anything" and you can see the panicked response from the pilot. So lucky they survived...

There's enough of these vids to make a good training package for all pilots to watch at a very early stage.
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Old 4th Sep 2022, 04:22
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..and another link from the other thread, thanks to Capn Rex Havoc.

By my reckoning, the glider pilot (having entered serious IMC at around the 2:30 mark) took about 10-15 seconds to lose it totally .... unless you are an experienced I/F pilot with, at the very least, limited panel instruments, VMC into IMC near invariably works out to be a bad outcome. That this pair survived involved nil management and an incredible amount of good luck.

Most of us who are rusty I/F pilots treat it with the same (very) healthy respect (fear ?) ...

(Can't say that I was impressed watching the slip string's gyrations along the way .... seems a lot of folks still view the rudders as footrests.)
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Old 5th Sep 2022, 01:31
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I have no first-hand knowledge of the course of the coronial proceedings as a result of this tragedy.

However, I’m completely unsurprised that the relatives of the deceased pilot or someone else brought the coroner’s attention to the ATSB report. The average punter would make the reasonable-though-naive assumption that the whole point of the ATSB’s existence is to find out why an accident occurred and that task would involve some deeper analysis beyond pilot error - given what we’ve supposed to have learned about these issues over decades.

But that seems to me to have presented the coroner with a conundrum: What evidential weight should be put on the findings and expressions of opinion contained in the ATSB report? For the reasons explained by the coroner, the answer was: Little-to-none. Absent some statements in the ATSB report as to the qualifications of the author/s and the basis upon which the findings and opinions were based, and absent someone from ATSB giving evidence at the inquest, that answer is pretty unsurprising to me. So the coroner is left with…

The relatives of the pilot who died in this tragedy aren’t the first and won’t be the last to be left bewildered - sometimes worse - at what the ATSB (and CASA) do and how they go about doing it.
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Old 5th Sep 2022, 02:08
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So what did the coroner come up with that the report didn't? What I read of the coronial report was that he was exonerating the company of any responsibility and simply stated that it was an unfortunate accident. The ATSB report went into the SMS of the company and that their system could be improved. They also come up with the same conclusion but with more aviation specific terms. ATSB reports, other than research reports, never have the investigator's name on it so I don't know why that is even mentioned as an issue. Its up to the coroner as to whether they accept a report or not as the basis of their findings. This one decided to not accept it ,as they are entitled to, but then took the extraordinary position to diminish that report and the ATSB because he said it had no value to him. Yet did not come up with anything that was significantly different except for stating that the company had no responsibility. The ATSB were investigating yet another CFIT or VMC into IMC accident trying to lay out why it might have occurred other than blaming the pilot. What I got from the report was that the company were encouraging (not forcing) pilots to have a look at the conditions and making their own judgement. Their assessment of the risks and their ways of dealing with it can be improved. Of course it can be improved as a pilot employed by them died. That the coroner did not even address that issue but stated that they couldn't have done any better suggests a complete lack of understanding of the purpose of an ATSB report. The company can wash its hands of the whole affair. Hopefully the family can accept that it was an unfortunate accident which makes the coroner's report worthwhile. As far as preventing further VMC into IMC accidents the coroner's report is as worthless as he considers the ATSB report to be. In years to come it will be interesting to compare the Qld coroners response to the ATSB report into the recent accident near Wivenhoe Dam. Reading some of the comments on that thread and how some pilots think they can beat the system with fancy avionics I think the coroners and the ATSB will be kept very busy. Lets hope they can learn to get along for the victims sake.
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