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Coroner not happy with ATSB

Old 25th Aug 2022, 14:26
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Coroner not happy with ATSB

A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy.

Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."

“One other obvious problem with the report … is that there is no indication of the author or author’s qualification to express the opinions and conclusions contained in it. In fact, there is even no indication as to the identity of the author or authors."

Mr Cooper said: "Perhaps most surprisingly, despite the fact that it was investigating an aircraft crash, the ATSB report does not appear to attempt to establish, at all, the reason for the crash.


https://www.abc.net.au/news/2022-08-...rash/101370152

https://www.atsb.gov.au/publications...r/ao-2018-078/
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Old 25th Aug 2022, 16:27
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What else did the Coroner expect? ATSB had little data with only ADSB track, altitude and ground speed.
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Old 25th Aug 2022, 22:41
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You do realise that we used to have an investigative body which was able to conduct very good investigations into aircraft accidents, without any ADSB track, altitude or ground speed data?
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Old 25th Aug 2022, 23:10
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Coroner’s Findings, see para [65] onwards for the conclusions re the ATSB report
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Old 26th Aug 2022, 01:07
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Originally Posted by Cloudee View Post
A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy.

Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."
But he then goes on to say [Paragraph 85:] "In my view, evidence enables a conclusion that until the very last moment of the flight, immediately before colliding with the Western Portal, Ms Walker remained in complete control of her aircraft. What happened in the immediate moments before colliding with the Western Portal can only be speculation." In his view?? Is he an aircraft crash investigator now?

I'm not saying it happened this way, but if you want to "speculate", what if she had issues with the autopilot at precisely the wrong moment like the young girl in the C172 that crashed into a hill NW of Melbourne not so many years ago?? It's the ATSB's job to rule that out.

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Old 26th Aug 2022, 04:26
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You need also to read paras 17, 18, 19, 39 and 40.

All day, nearly every day, coroners deliver findings as to causes of death in circumstances in which the coroner has no personal expertise. That's their job and that's why they like to be assisted by people with expertise in the subject matter.
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Old 26th Aug 2022, 04:39
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Aaaahhh, Tasmania, on a good day it's Gods own, on a bad day it's Hell, except for the temperature. I'm afraid the young Lady died of her own hand, in as much as pressing on into weather, anyone who has flown in the place will have their story of trying to operate in VMC. Used to regularly fly Hobart to Melaluca, a strip just south of Bathurst Harbour, very rarely went direct, only once that I recall in fact, always tracked down the east coast, then along the south to destination. Once had to do a semi circumnavigation of the state to get from Strahan to Hobart, up the west coast, along the north to Launceston, down the valley to Hobart. Refueling at Queenstown one day and a Cessna single landed with two lads and girlfriends with shrubbery hanging, from Hobart and had got caught in a valley, hit the trees on climb out, aircraft undamaged, though their psyche must have taken a hit. Did a lot of work with survey teams, land on top of a mountain in clear weather then have to pack up and make a run for the aircraft when a cloud cap suddenly formed, hovering down the side of the mountain with eyeballs on stalks until getting VMC. Glad to leave the place, only because of the flying risks that were difficult to outflank.

Once took a week to wait out weather before we could get into the high country south west of Cradle Mountain to rescue a climber with a broke back. Closest we could land was about a mile away and carried him on a stretcher, flying home I found myself covered in blood, leeches had snuck in everywhere.

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Old 26th Aug 2022, 05:11
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though their psyche must have taken a hit.

Can be a worry when that doesn't apply.

A case in point. Years ago, up at Kyneton, doing some engineering work ...... Cloud base a whole lot lower than I would have chosen to fly in VFR. Along comes a little single from a well-known and large training organisation in NSW. Low circuit and landing. Some youngsters clamber out.

I had a relaxed natter with the pilot. Now we all have frightened the living bejezus out of ourselves on multiple occasions in nominal VFR operations. My prime concern talking with the young fellow was the observation that he was quite relaxed about the preceding flight - what should have frightened him witless had had no apparent effect on him - big worry there. Turned out that his father was one of our 767 captains so I had a natter with dad when convenient and related the tale so that dad might be able to have a beer and a chat about this and that with the son. Father was quite grateful for the opportunity to be able to point out a few things to the youngster.

How we actually managed to get through our first 1000 hours, frightened but not scratched, often causes me to shake my head .....

that's why they like to be assisted by people with expertise in the subject matter

My concern, reading the reported tale, is that one might wonder whether the coroner might have done better insisting that he actually did have such expertise available to him during the coronial ? His reported comments suggest otherwise ... ?
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Old 26th Aug 2022, 05:45
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Its important to read why the coroner found the report lacking, towards the end. Its more about the speculative aspects that poke blame on Par-Avion, CASA and the BOM, without any evidence to support the assertions. Considering the amount of flight data the coroner seemed to have including aspects of attitude at impact I can see why he was having a go at the ATSB for not finding a cause.

After all the ATSBs job is to investigate the cause of an accident. The coroners job is to find cause and factors leading to death (in short).

The coroner was obviously intrigued by whether there was some cause outside of 'pilot misadventure' that needed to be looked at. With statements along the lines that Par-Avion 'encouraged' pilots to depart in marginal to poor conditions sort of hints that the company and others may have shared some blame. Effectively getting to the end and saying your report wasted my time, do better next time.

There may have also been some questions over survivability and the delay in reaching the site, which I think were definitively answered in that report.
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Old 26th Aug 2022, 06:38
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I had skimmed the ATSB report AO-2018-078 some time back prior to reading the ABC news item with the coroners fairly scathing remarks about the report. I have taken another look at what ATSB wrote and, without reading everything, I still think it seems sensible and makes a reasonable assessment of what most likely happened, including the 'reason' for the crash: "While using a route through the Arthur Range due to low cloud conditions, the pilot likely encountered reduced visual cues in close proximity to the ground, as per the forecast conditions. This led to controlled flight into terrain while attempting to exit the range". Not sure what more was expected or was possible for ATSB to establish?

It is also noted that a draft of report was provided to Airlines of Tasmania, CASA, BOM and others and that in response submissions were received from all three and the UK AAIB. Those were reviewed and, where considered appropriate, the report was amended. So the report has some independent review. Perhaps ATSB should include relevant state and territory coroners in the release of draft reports where accidents involve fatalities so that coroners have an opportunity to comment before a final report is published by the ATSB? [Update: ATSB did just that for the report into the C130 N134CG crash at Peak View: "draft report was sent to the NSW State Coroner for information"].

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Old 26th Aug 2022, 06:38
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My concern, reading the reported tale, is that one might wonder whether the coroner might have done better insisting that he actually did have such expertise available to him during the coronial ? His reported comments suggest otherwise ... ?
The list of witnesses at para 17 seems to include some people with considerable aviation expertise, though it might be argued some of them had at least apparent conflicts of interest. I think 43" makes a good point: The statements in the ATSB report naturally raised issues and questions beyond just pilot error but the coroner had no witnesses independent of the operator to give evidence on those issues to help answer those questions. And, for all the coroner knew, the author/s of the ATSB report could have been the Year 10 work experience kid/s. The operator naturally argued that there was no credible evidence before the coroner to support findings equivalent to some made in the ATSB report.

The ATSB's usual practice of refusing to get involved in coronials has its disadvantages...
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Old 26th Aug 2022, 10:54
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The list of witnesses at para 17 seems to include some people with considerable aviation expertise

I don't dispute that although it would be useful to review what those witnesses may have had to say in detail ?

I find paras 32, 33, 35, 40, and 59 somewhat rather more interesting than para 17 ?


Most of us, in our earlier flying days, have been in circumstances, whilst flying "VFR-ish", which might be similar to what this pilot experienced. Most of that group managed to survive the experience, often more by good luck than good management, I suggest ? A few such frights and the wise VFR pilot builds in a bit more conservatism to the in-flight decision-making processes. Personally, I think the long-running PNG thread on this site ought to be mandatory reading for all newbie VFR pilots .... we might not have that sort of tiger country on the mainland but, in patches, it can still kill one in the blink of an eye should one let one's guard down in adverse weather ...
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Old 26th Aug 2022, 11:34
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It may be possible to get transcripts of the hearings or copies of affidavits made, but I haven’t confirmed that.

My reference to para 17 was merely in response to your expressed concern about the qualifications of witnesses.

Many of the other paras were ‘interesting’, including the specific ones you mentioned, in relation to what the coroner found as a matter of fact. Very tragic and so avoidable in fact (in my view). The pilot’s experience on the aircraft and route flown should have been enough (in my view) to enable to the pilot to make, and be confident in making, the call to turn back/avoid or whatever..
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Old 26th Aug 2022, 12:59
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The pilot’s experience on the aircraft and route flown should have been enough (in my view) to enable to the pilot to make, and be confident in making, the call to turn back/avoid or whatever..
I think that is what the Coroner was getting at with some of the comments. The ATSB included in findings/recommendations that more information to pilots should have been available, but in this case it would probably have not altered the outcome as the pilot was significantly experienced on the route and familiar with weather patterns. The same could be said of commercial pressure or 'encouragement', this pilot would most likely have known when to say no in most occasions except this one. The coroner seemed to think on evidence that it was a reasonable decision for the pilot to depart and follow the route they did on meteorological information available. And the part about a recording device, really, what sort of recording device are we talking about, they already know the flight path and attitudes at impact. Are we talking about a CVR in a single pilot aircraft just in case the pilot is talking to themselves, or are we talking video recordings, which has always been a big no-no among pilot groups. FDR and CVR will most likely not shed any more light on what happened, it definitely will not really show much in the way of weather outside reducing visibility, unless it was heavy rain or hail. Its nice to mention these things, but when do you stop before getting to the point that they say they need some form of 'time machine' so they can go back and watch what actually happened.

I think the critical aspect is focused on the 'Crash Investigation Report' being turned into a safety advisory and not focusing on the crash and it's actual cause, rather proceeding directly to identify deficiencies within the company not directly related to the accident.
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Old 27th Aug 2022, 01:11
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The coroner seemed to think on evidence that it was a reasonable decision for the pilot to depart

I'm sure the coroner approached the question in an appropriate and reasoned manner for the role and consistent with whatever evidence was led and background knowledge.

Unless it's a case where blind Freddie can see (or should have seen) that it's a no-go situation without any redeeming option, I have no problem with a pilot's heading off to have a look see. We've all done that, have we not ?

However, the problem potentially then arising is the flight management question/strength to make the call in marginal conditions to do something different rather than just continue with crossed fingers. It's a bit like checking - either do really well so it's a programmed pass, or really bad so it's a programmed retraining or another check ride, but don't pussyfoot about on the yes/no fence line so I have to make a decision. I wasn't there so I have no idea what the pilot specifically did or didn't observe on the day. Just a dreadful waste of a young talent and life, with the benefit of 20/20 hindsight, that she chose the course of action she did ?

A bit like the two young fellows on the east coast, years ago. I didn't know them but knew one's mother and her parents well when I was a child from family friendships so it was a bit close to home for my liking.

Most of us have been there, done that, got the tee-shirt and, somehow, managed to survive the experience with a greater or lesser degree of terror at the time. The eternal operational question remains - how to put older heads on younger shoulders ?
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Old 27th Aug 2022, 01:23
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I think the real key is why did she cross the 'portals'. The statement from the helo pilot gives some clue that he could see light through the gap. This is probably what the Islander pilot saw as well, bit of light, the mistaken belief that beyond the saddle was wide open clear air, combined with the web cams at Bathurst Harbour showing OK conditions once she had passed that point. After crossing that saddle and it closing in behind then there are very few options, so in a way its a critical location. She obviously tried south, then north to no avail and then tried to get back through the saddle. Once she had crossed the 'portals' her fate was sealed, that is the critical point in this, from there she was trapped in a weather bowl with the choices being land on whatever suits or try to fly through some bad conditions to freedom.

The point here is that if flying through tight spaces, make sure when you pass critical locations that you are certain that the path ahead is clear and that the pass behind is not subject to rapidly closing. I think here the idea that there was multiple options to use after the portals gave the pilot some confidence to continue through a very small gap and then found out that in some rare circumstances all routes out of the next valley become blocked.
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Old 27th Aug 2022, 01:32
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... bit of light, the mistaken belief ...

Hence the value in newchums' having a think about the operational wisdom contained in the PNG thread ...

First time I got suckered into the gap trap was donkey's years ago from BK heading over the hills west as, very much, a newchum. Got myself trapped but got out of it. The lesson never left the forefront of my thinking in VFR bad weather flying. Subsequently, I wanted a big gap to continue and a rear window to keep an eye on what was going on behind me.
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Old 27th Aug 2022, 01:35
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And the sucker holes are everywhere, from saddles in mountains to small holes in overcast you think you can safely climb through. To the gently lowering cloud bases that lure you into a corner and when you turn around its lower again. Maybe VFR pilots have to live with idea that cloud is a living intelligent force actively trying to kill them, so stay well away from it and treat it like an apex predator. It can even spit rain and hail on you from afar to confuse the unwary horizon pilot.
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Old 27th Aug 2022, 02:42
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And the sucker holes are everywhere,

.. isn't that the simple truth. I was lucky, I did my PPL on an ATC scholarship. Finished min time and Jack/Stan (RNAC) figured we should spend the remaining 15 hours or so (before the RAAF found out I'd finished the licence) under the hood doing circuits and aerobatics limited panel. Helped to save my bacon on a few occasions since ... That first trap for me saw me up into the scud on the clocks, stall turn reversal and, fortunately, the way in hadn't clagged in totally. Probably would have been a different ending had I not had some I/F aeros behind me and not all that long before.
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Old 30th Aug 2022, 02:01
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3 lost west of Brisbane Monday 29-8-22 - PPRuNe Forums

Post 6 provides some sobering photographs of weather.

The photos may not be what the pilot saw but, in terms of this thread, are very illustrative of sucker bait situations going over/through areas of hilly terrain. A slight change in temperature or wind (or a couple of hundred feet increase in terrain elevation) and photo 1 can turn, very rapidly, into something like photo 2.

(I would hope) it is not likely that anyone would push on in conditions of the second photo, but the first is just so typical of what can tease the (inexperienced or overconfident) pilot into a dead end trap from which there is no way out.
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