Accident at Shellharbour

[Jenna Talia]

Originally Posted by Lead Balloon

If they took off on 34, 15G25 from the west might also have created some challenges.

The FR24 track indicates a takeoff from 26. Regardless, it would still be challenging.

[tartare]

Eyewitnesses (often unreliable) quoted as saying it reached about 30 metres altitude before `dipping' and left wing striking tarmac.
Possibly a stall - fierce fire - only empennage left - maybe he had full load of fuel.

[Lead Balloon]

Originally Posted by Jenna Talia

The FR24 track indicates a takeoff from 26. Regardless, it would still be challenging.

Thanks JT.

[VH-MLE]

From 43Inches: "I think I've alluded to it several times that the accident rate in light aircraft in Australia is significantly higher in the last 20 years than the late 80s through the 90s, it started significantly climbing in the mid-late 2000s. My take is the introduction of competency based training, which over complicated the learning process in an activity that needs clear safety focus, simple objectives, not 100 competency items. Not saying that competency based training is a bad thing as a concept, just that it took an activity where instructors often trained to "are they safe" standard, focusing on making sure they were able to survive, then CBT adjusted that to a set of numbers means they are safe, they are good to go, numbers all say they are safe, here's a licence. So it was all about poor implementation. Added was the drying up of experience in GA and that experience not being passed on to the new generation of instructors, so the concept of what is safe in regard to those numbers was also lost."

I would agree & go further & say that the CAA disbanding the Examiner of Airmen system in the testing for professional qualifications i.e. CPL & instructor ratings the late 80's, started the decline in piloting standards in this country. This is perhaps a discussion topic for another thread, not this one at this stage...

[KRUSTY 34]

Originally Posted by BronteExperimental

I was airborne traveling south coastal to Vic at 8k when the airport was closed. Only found out what happened when I landed.
Worst day of flying for me in a long time. Sev turb and sev mtn wave sigmets. 55kts+ of westerly.
whole flight at Va and plenty of +\- 1500 fpm up and down drafts.
I can imagine that the turb below the escarpment there today would have been significant.

My thoughts as well. Flying in and out of Canberra this morning. Nasty rotors abeam Mt Madura, and lots of significant turbulence below 8000. Thought of the conditions at SHL. Obviously we’ll have to wait for the report. Very sad day.

[Capt Fathom]

Why do pilot's go flying when Severe Turbulence is forecast? You might think it's all a bit of fun, but your passengers would more than likely be terrified!

[John Kasuku]

Originally Posted by Lead Balloon

Thanks JT.

With the topography to the west and gusty winds to 32 kts reported, rotors would have been severe. The shortish take off roll would be explained by the stiff headwind. If the rotors resulted in a 20kt change in IAS at the reported 100' altitude I can see how a stall might develop so quickly even quick action by the pilot might not have been enough.

[nomess]

Having supported a friend who lost both parents in a car crash, this is hard to read this one, and I feel for the kids who have lost both parents here. It’s one thing grieving for loved ones near the end of the life expectancy, but to have both parents taken away in an instant, without the final goodbyes or anything, just gone, is tough.

I hope the industry takes learnings from this and we can prevent further loss of life.

[Newhairdo]

Originally Posted by 43Inches

My take is the introduction of competency based training, which over complicated the learning process in an activity that needs clear safety focus, simple objectives, not 100 competency items. Not saying that competency based training is a bad thing as a concept, just that it took an activity where instructors often trained to "are they safe" standard, focusing on making sure they were able to survive, then CBT adjusted that to a set of numbers means they are safe, they are good to go, numbers all say they are safe, here's a licence. So it was all about poor implementation. Added was the drying up of experience in GA and that experience not being passed on to the new generation of instructors, so the concept of what is safe in regard to those numbers was also lost. We have all these MOS, pages upon pages of what should be done, where and when, and look at the result... Over complicated, result, people dying. The rule sets were never about safety, ever since Seaview it's about being able to prosecute and protecting the regulators arse from litigation. It was always amusing when one of the first things brought about with CBT, was the student signing the bottom of a page full of competencies after each lesson, in a statement that they have received training and agree with the instructors assessment and comments. After all a learning student is going to understand all the numbers and complicated statements regarding what they just did, half of which was a blur to them in cognitive overload....(sarcasm)

Personally, I believe that CBT is an excellent concept.
But…………….Not here!
I agree with what you appear to be suggesting, that is that CASA have no clue about what CBT really means, how to design it and how to regulate it.
The MOS (all of them ) is a joke. It appears to be a made up list of subjects written by lawyers. Look at any MoS - it’s not about delivering the best training in the best way, so that the student has an effective learning experience, it’s about regulatory @r5e covering!
I haven’t seen a single well written MoS.
So yes, I believe you are right when you suggest that we need to go back to basics.
In my view, this all stems from a regulator that doesn’t really understand its role anymore, and one which appears to have stripped all experience from its ranks.

[UTW]

Here’s another theory…

• In some older Piper aircraft (including Cherokee Six, Lance, Saratoga, PA-28, and PA-32 variants), the seat-track locking mechanism or rear seat retention pin assembly could fail to engage properly.
• When that happens, the seat can slide suddenly rearward under acceleration — particularly during take-off roll or initial climb when power is applied and G-forces act rearward.
• The sudden motion can cause the pilot to lose reach of the controls, often leading to a pitch-up and/or loss of control.

[Peter Fanelli]

Originally Posted by Capt Fathom

Why do pilot's go flying when Severe Turbulence is forecast? You might think it's all a bit of fun, but your passengers would more than likely be terrified!

GetThereItIs

[43Inches]

Originally Posted by Capt Fathom

Why do pilot's go flying when Severe Turbulence is forecast? You might think it's all a bit of fun, but your passengers would more than likely be terrified!

As already said, Getthereitis, is the main reason. However Severe turbulence forecast lee of the ranges is very common with moderate to strong westerly flows. I know Melbourne could have severe turbulence warnings for weeks and no one ever experienced it. This can be the issue if you are too conservative with forecasting, the users get used to seeing it written, fly and only experience smooth air, so become complacent with it. It then really comes down to local knowledge and how experienced/trained the pilot is at their own observations as to whether such conditions exist. I know most pilots, at all levels, are not great at weather appreciation in this area. I remember watching other crew when airline flying, the experienced ones would lower the seat and tighten belts, almost subconsciously, when they sensed a turbulent encounter coming, these days some don't even get the seat belt sign on before coffee goes flying.

Personally, I believe that CBT is an excellent concept.

I agree, the concept has merit, however the implementation was beyond poor, and has actually resulted in a loss of standard. I put most of that down to the early days, when the competencies were used as a syllabus, and not enough focus on technique. It only takes a few years of bad knowledge transference to drastically affect the whole industry, and that happened in the early 2000s due to the drain of experience combined with poor transfer of technique based instruction to the next generation.

[hatti]

A previous accident that occurred with the same type same phase of flight, VH-ITR 1998 King Island.

[Clare Prop]

CBT is more a system of recording and measuring evidence of competency against a standard that the instructors and examiners use to assess competency. It doesn't say "how" to do the training, and is outcomes based. I am aware that many instructors and nearly all students aren't even aware there is a MOS, even though a good knowledge of it is required in the instructor training syllabus..

I think the declines in standards are more to do with CASA continuing to allow flight tests to be conducted by employees of organisations, among other things such as bulk training of students in large cohorts with inexperienced instructors. The only way to eliminate bias as far as possible is for all examiners to be independant.

As for this accident, I'm trying to make sense of the FR24 plot. Did he turn left crosswind then attempt to turn back and have a loss of control as a result? Low level turns in strong winds are likely to lead to disorientation.

[43Inches]

As for this accident, I'm trying to make sense of the FR24 plot. Did he turn left crosswind then attempt to turn back and have a loss of control as a result? Low level turns in strong winds are likely to lead to disorientation.

It sounds like it all went wrong just after airborne, under 100ft, so doubt it was a crosswind turn. The previous post relating to seat issues is a possibility, the PA32 series have a long seat travel, although it is hard limited by the spar box area, a raised area that the mid seats sit on. If it did slide back at rotate it would be seriously difficult to control, even more so if out of trim or the pilot tried to hold onto the controls. Unfortunately it looks like the ATSB has little structure left to analyse, so it may never be known what happened, unless some form of internal or external video sheds more light.

I think the declines in standards are more to do with CASA continuing to allow flight tests to be conducted by employees of organisations,

Examiners only get a small glimpse of the standard of an individual under test. Whether a pilot is competent is all to do with what happened during training, so whilst a strict examiner is the last gate in the process the instruction at each stage is the vital part. Instructors can undermine the test process by training candidates to "pass the test" rather than be competent. That was the real purpose of CBT, to have a record of progress that should show the candidates journey towards the final test and that all areas achieved the standard before the test is taken. However several issues with such systems arise. Do the instructors actually mark the students accurately? Do they know what a 3 or a 2 means? Are they training students for a particular testing officers nuances? Are they just preparing them for a test rather than preparing them for the real world after the test? Does the instructor have the right techniques and aptitude to pass on the knowledge to the student? I could go on with many other questions, however the point being examiners have only a small part to do with competency in aviation.

[Squawk7700]

Originally Posted by hatti

A previous accident that occurred with the same type same phase of flight, VH-ITR 1998 King Island.

Wow, that is eerily similar. Seems they pointed to W&B.

https://www.atsb.gov.au/publications.../aair199805365

[Seabreeze]

Weight and Balance

Originally Posted by Squawk7700

Wow, that is eerily similar. Seems they pointed to W&B.

https://www.atsb.gov.au/publications.../aair199805365

With 3 Pob it is very hard to believe it was either a weight or balance problem. Seat slippage or pilot medical event are the 2 most likey IM inexpert O.

Maybe an engine failure contributing, but less likely as he would have landed straight ahead (maybe)

A previous departure, just a few minutes earlier seemed ok, turbulence notwithstanding.

Why hasn't someone asked GT to shed light?. He is famous for his knowledge of all matters aviation.

[43Inches]

Originally Posted by Squawk7700

Wow, that is eerily similar. Seems they pointed to W&B.

https://www.atsb.gov.au/publications.../aair199805365

I did think of this accident when I saw the profile. I remember it well as I was flying PA-32 at the time. The difference being this seems to be only 3 POB, so lighter in weight, however the profile does seem to be very similar, I wonder if they had a lot of gear/bags in the rear. Anyone who has flown the Lance would attest to its very sluggish low speed handling, it really is an aircraft that you have to be disciplined in keeping the speed up to perform. The shorter slab wings also have less in the way of spin prevention that the later tapered, washed out, wing Saratogas have.

[Squawk7700]

I was thinking along the lines that the winds were similar in the King Island event. The KI occurrence was at the crosswind limit which is interesting, with decent gusts and a similar takeoff roll.

[Clare Prop]

Originally Posted by 43Inches

However several issues with such systems arise. Do the instructors actually mark the students accurately? Do they know what a 3 or a 2 means? Are they training students for a particular testing officers nuances? Are they just preparing them for a test rather than preparing them for the real world after the test? Does the instructor have the right techniques and aptitude to pass on the knowledge to the student? I could go on with many other questions, however the point being examiners have only a small part to do with competency in aviation.

Very good points and you are right about the examiners being the final gatekeeper, but having been one for 30 years I know how you can quickly find gaps in knowledge - often at the pre flight stage. As soon as the candidate answers a question with "My instructor told me...." you know they have not got past the "rote" stage of learning.
I get files transferred where it is clear that the instructor has just done a "tick and flick" exercise, because some of the packages people use are very cumbersome and most instructors are time poor. The student denies any recollection of some of the exercises and was given no feedback but been given a "1". Instructors have come to me looking for work who have never seen the MOS, so of course the whole exercise is meaningless. in those cases. So a lot of the problems arise in the training of the instructors in the first place. Again, an independant examiner would be able to recognise that very early on in the test. But yes, there are a lot of holes and I think although the instructor training syllabus is very clear but some places just aren't following it.