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Fatal crash pilot should not have flown: coroner

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Old 2nd Jan 2003, 06:18
  #21 (permalink)  
 
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Whose Fault

The facts are all there, and so are all the casual factors.

I agree with Shipwreck, the casual factors are the reason this crash happened. If these did not exist then the accident would not have occured.

The CAUSE of the crash occured at Kiwirkarra, where the pilot failed to ensure that sufficent fuel was onboard the aircraft before departure. Is this a fault with the metod of calculation or flight planning ??. At this time the pilot would also have been aware he was going to be arriving at NWN after dark, but he still departed. I can't remember the actual name given to deliberatly diregarding rules and regs (ops manuals) but it was covered in the EA CRM course last year.
I believe that a significant number of accidents occur due to this reason. I also believe that this cause is signifcantly attached to the attitude of the operator or organisation therefore making it a casual factor in this accident.

The corroner identified that the pilot was not approved (NVFR-ME)to be flying the aircraft and this true, but like many, I belive this is a side issue.

I don't believe that the WA Police should be running an AIRWING, it should be conducted simmilar to the QLD Gov (PS) Airwing or NT Airwing with civilian (PS) pilots and suitable aircraft.

Policing is very political in WA with BUDGET restraints and police on the street, always the main issue. This is to blame on the GOV the Public Service and the Police service and should not be forced upon the members of the service trying to do thier job.

I lost an old friend in this accident, I have read with interest and tried to follow the ball (FACTS).

It is my belief that The PILOT is to blame for the crash and the loss of life, and that the reason he was there was due to failings on the part of the Police Service and the Police Air Wing!.

I have recommended this to the family of my friend.

RIP Dave

PS I am astonished to see that the Police is offering a 750K commpo package to the famillies, and am I correct that it is bieng kept quiet??, if so it stinks of KEEP QUIET money.
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Old 2nd Jan 2003, 07:25
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Amraam

The CAUSE of the crash occured at Kiwirkarra, where the pilot failed to ensure that sufficent fuel was onboard the aircraft before departure.
I am very sorry you have lost an old friend but have you read the ATSB report? The aircraft arrived overhead Newman with an estimated 165 litres of useable fuel and about 30 litres was drained from the auxiliary tanks at the crash site.

Quantity of fuel was not the issue, its location was.
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Old 4th Jan 2003, 02:36
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Hand over the police air wing and a budget to the RFDS. They have the turbines and the infrastructure.
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Old 4th Jan 2003, 03:05
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Traffic

That is too sensible and practical solution to the farcical operation under which the Members of the service have laboured so far, to even get close to being considered as a result.

The pollies are driving around in the very same equipment that access to which the Police should have priority.

Pollies are being flown to open the local fete in the Citation or King Air, whilst the plod are struggling out to the Central desert and the like in a C182 or clapped out C310 and Chieftains.

Problem is the Police service themselves do not have or are resisitant to taking on board the expertise that they need to present their case for the huge budget, that is not only a necessity, but required for them to properly execute their responsibilities.
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Old 4th Jan 2003, 04:50
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MINISTER CONSIDER THIS

The Politicians do indeed fly around in sophisticated aircraft doing all things political, including flogging off the occasional personal cd or cassette.

The aircraft that they use are operated under contract by Civilian organisation/s to a very high professional standard. (correct me if I am wrong here, please)

Understanding how tight fisted the Police & Government budget bean counters are this is what I believe should be done to address the inadequacies of Police in aviation.

1. Immediately increase the police rotary wing aircraft to a minimum of (2) with a budget sufficient to permit an absolute minimum of 4 hours flight time per day, per aircraft (2 hours day & 2 hours night each)
2. Relocate these helicopters to the old Maylands Police academy where they are centrally located and can be hangared in the already existing hangars. This would mean they would have instant access by the elite and be a stone throw away from Police Head Quarters, Perth Airport, Hospital etc... (on numerous occasions valuable time has been lost due to travel time in getting to Jandakot.
3. Staff the helicopters with Civilian staff including Chief Pilot, not Police and pretend Police (deputies). ensure a chain of command that is civilian direct to the Commissioner & incorporate CASA at that and all levels.
4. Immediately award all Police fixed wing travel to the civilian Government contractor, this guarantees the use of safety appropriate, sophisticated aircraft for rapid long distant travel, with Government picking up the tab through consolidated revenue or SPEED-CAMERA fines.
5. Establish rapid deployment protocols for your elite between Maylands heliport and Perth civilian operator, this would allow state-wide coverage within hours.
6. Immediately disband the Police fixed wing unit and send the staff back to their primary jobs of boosting the Police numbers on the street.
7. In remote areas utilise local approved civilian operators for search & rescue and fixed wing travel, this already happens in regional areas.
8. Get rid of the Jandakot hangar, you don't need it... obtain an office in the civilian fixed wing operators complex if you really must have a civilian liaison there, otherwise just do what everyone else does, phone, fax, page, internet.....

Minister consider this....
You will need to buy another chopper, some civilian crew, refurb an old hangar at Maylands and put in a heli-pad. You will cop a bit of flack from the residents, but hey the fight on terror stance can take care of that.

You will gain a tactical advantage for the rapid deployment of special operations, extra Police back on the streets, credible air support unit that actually provide assistance to ground troops. Instead of being 2 days late and $2 short all the time. Along with this all Police Staff travelling fixed wing will have the knowledge that they are flying in state of the art aircraft with highly experienced civilian crews who actually hold the appropriate ratings and licenses.

GOOD ENOUGH FOR YOU TO FLY AROUND IN, GOOD ENOUGH FOR THE POLICE.

IT CAN ALL BE FUNDED BY A COUPLE EXTRA SPEED-CAMERAS, I for one would feel a lot happier paying a fine knowing that the money is actually doing something positive that can be seen every day up in the sky.
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Old 4th Jan 2003, 09:26
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Sipreck

I have to seriously wonder how much you know about aviation, or whether you you have a certain angle to all this.

You deem the WA Police Service as being incompetent in the running of a Fixed Wing Unit but then in the same breath consider them okay to run Rotary.

Just in case you were not aware of it, rotary:-

Cost more in intial costs, more in training, more in maintenance, more in crew training, etc etc etc and when I say more I mean much much more.

Now you reckon they can't run a C310 safely how do you resile that comment with allowing them to operate Rotary in the demanding role of Polair and Ambo ops.

Let me assure you, any organisation that can do that, could run fixed wing on their ear.

I also take note of one of your previous comments and can no longer hold back from commenting on it.

On more than one occassion the op's manager or Chief Pilot in the companies I have worked, have said NO to us the Pilots, which at the time really piissed us off becuase we took it personally and a slight on our abillities, not to mention the log book hours being missed out on.
Good Grief.

I hope your OPSO/CP wiped your botty as well.
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Old 4th Jan 2003, 14:19
  #27 (permalink)  

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Square Bear

On the evidence, whilst the Police Service are structured as they are at the moment, they are not competent to run EITHER rotary or fixed wing in the required role.

They have come from completely the wrong direction and have been led up the garden path by well meaning 'amateurs', notwithstanding that the 'amateurs' may hold "professional" qualifications.

Throw in the usual political train smash from both sides and why are we surprised at the events. I am only surprised it hasn't happened sooner.
They only got out of the helo accident relatively unscathed by good luck rather than good judgement.
Then they turned the insurance money from a helo that they could afford and did a real job for them, into one they couldn't and doesn't.

They need to get their "colleagues" from Vic, NT and QLD to come over and give em a good talking to, on how it really actually works.

Problem is, they are so used to telling everybody else what to do, they have forgotten that they don't know everything.

Unless I'm mistaken, the attitude that seems to prevail and prevents them going forward on this, is that you are either a member or a suspect.

We have the biggest, least populated, most difficult to police State in Australia and we are stuffing around with a C182 and a couple of clapped out old piston twins.

There is much sense in what shipreck proposes, especially in relocating the helo ops to Maylands and there is absolutely no doubt that the fixed wing ops are better and more conveniently located at Perth Airport.

They need at the very least,
New or very near so, crewed by experienced and professional pilots, they can make em coppers if they want.

A Dauphin type for the heavy and longer range work.
A couple of Squirrels for rapid response around the metro area and out to around a 150nm radius.
With more than one helo around there is a reasonable chance that there will be one available when you really need it.
The helos IMHO need to have the starflex rotor technology or something equally advanced.
A Citation Bravo for the longer distance liaison, whilst they wait for an Excel and a Sovereign and
A Citation or Citationjet 2 for the closer in stuff.
Four Cessna 208s, one in Perth and the rest rotated out at say Kal, Hedland and Broome.

Anything less and they simply can't do the job that they are expected to do with the manpower available.

Simply from a duty of care perspective having officers thrashing around the countryside in cars at high speed by road or trekking through the bush in a 'cruiser for 14 days to check on a couple of communities just doesn't cut it.

And what are they going to do if they have to respond to an "emergency" or "disturbance" in the country or NW, wait for the RPT??

Give 'em a break.

That is where the Multanova revenue raisings should go, then they can give away the bulls hit justification they keep serving us up, about road safety.
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Old 5th Jan 2003, 00:28
  #28 (permalink)  
 
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Gaunty

Sadly you are probably right. I will however send Gallop a note and see if can at least get above the level of Sir Humphry.

I recall some dozen years ago the WA Police pranged a helo into the Kelmscott Primary School playground. They then turned around and wrote a cheque to a Japanese company for a Kawasaki to replace it. This was done through some agent in Melbourne and noone actually sighted the a/c before the cheque was written.

Problem was the people to whom they wrote the cheque didn't own the helo.

It took a lot of work from a mate of mine in Tokyo who ran the Westpac office at the time to sort out the mess. This included very senior representations to Japanese government. They finally got their helicopter and we and all the kids got a flight in the thing and a big lunch at Rotto for saving the day.

IMHO there is no way the WA Police can operate a credible airwing.

The last time I spent any time at Jandakot...in October last year, the RFDS PC12's and King Airs came and went but there were always 2-3 a/c on the hardstand doing sweet FA. I am sure they would be pleased to be more gainfully employed.

FWIW
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Old 5th Jan 2003, 02:14
  #29 (permalink)  

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I well remember that prang and the purchase fiasco that followed as I worked for the company that was in the business of an Aerospatiale joint venture for helos and fixed wing at the time.

We knew exactly what was going down and why, but the "Force" as it was then called, were entirely resistant then, as they appear to be now, to simple common sense.

They pulled a similar stunt when they replaced the C182 by brokering a brand new one (they obviously thought it was going to be cheaper although we never found out what they actually paid) through the local Piper Dealer, if you can believe that.
We also had stock in the country.
It was also done without the benefit of any formal tender or purchase process.
They then got all bent out of shape when we as the Distributor dealer insisted that the warranty service and parts they were entitled to, be paid for first and they could then make the claims against the actual selling dealer in the US. This was in the Cessna rules at the time in an attempt to stop dumping and protect the very significant investment they required for Dealer status.
We got the Factory rep on one of his trips down here to talk to them and explain the error of their ways and eventually sorted a warranty process out, but we were not obliged to.
They did not seem to understand the corollary that was offered in buying their Holden Fleet through a Ford Dealer.???

It goes on, but I've got to go to work now.
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Old 5th Jan 2003, 03:33
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Dear Square Bear

I believe you are way out of your depth here. Thanks for reading one of my previous posts, sadly you didn't understand that one either. The quote was in reference to best practise and safety, I sincerely wish the Chief Pilot or OP's Manager of the WA Air Support had said NO to the Newman 310 Pilot .... If he had, 4 people would be alive today.

The tone of your email suggests you are more interested in defending the Police air Support unit than addressing the inadequacies of it, which leads me to believe you are probably a Police Pilot scared to go back to the job you are being paid 65K per annum to do. how many C310, C182, B58, PA 31-350 pilots get that much?)

As far as running a 310, I think the WA Police have demonstrated in tragic style that they can't run an aviation operation competently.


Helicopters on the other hand are the only viable aviation tool that can be used in the metropolitan area for search & rescue, Tactical Response deployment, Terrorist-siege incidents and such like. What do you propose re open Langley Park and land the C182 there when you need to deploy troops, drop rescued & injured persons ????

If you had bothered to digest the point, the Rotary Wing operation is Civilian operated and managed and reportable to only the Commissioner with CASA involved at every level. In other words no Assistant Commissioner or other person can override the manager, only the Commissioner and then with the knowledge of CASA as a safety monitor.. Complies with being open and accountable...

As for the cost of rotary winged aircraft, sure they are expensive and selling off the clapped out fixed wings will go some way to paying for it, along with the sale of the Jandakot hangar, the reduction in aircrew salaries and management costs, I reckon there is probably $1.5M saved, now add the revenue of 2 speed cameras that should add up to approx $2.5M per annum I think the lease payments are safe with that and well, 7 or 8 extra cops on the road that don't have to be replaced by new recruits at $145K to train each and 6 months in the academy and the next 3-5 years street experience before they realise their full potential ....

I don't think for one minute the Police Pilots will leave the government job,,,,, because they will never get a job with that much dough in General Aviation, especially not with the benefits they get now and most are too old for airlines or any regional operator anyway...... MINISTER TAKE NOTE HERE!!!!!!

I think the focus should be redirected back to response time. I should imagine response time is of paramount importance to the Police and that is what is achieved by moving the heli ops to Maylands and fixed wing to Perth, hell the time and fuel saved in driving to Perth or Maylands as opposed to Jandakot would add up to significant savings in time & money by itself.

GAUNTY

I think you have hit on probably the most sensible & Cost effective idea, incorporating the RFDS, and they already have regional bases established all over WA.

The Northern Territory Police have proved the worth of the PC12, so why not forget the regional Police fixed wing idea and go with the RFDS providing fixed wing state wide and supplemented at a local level by local charter companies. Search & Rescue is already assigned to civilian operators around the state, so MINISTER jump to it.

The RFDS have a very good safety & performance record with excellent check and training procedures and by coincidence are carrying Police personnel virtually daily on all manner of circumstances, escorts, searches, crime victims etc.

I wonder what the Tactical Response Group would think about having direct access to helicopters 24/7??????...

As the first line of defence against a Terrorist threat I reckon it can't be beaten.

What's the alternative..... Black Panel vans driving at high speed...(slow and risky overall) or maybe waiting for a rotary wing pilot to get out of bed drive to Jandakot, pre-flight, and fly-over to pick them up.... Always a day late and a $ short.

I think what we are all saying in various ways and tones is that the Government must get serious about this issue and provide the funds directly into an Police aviation account that can't be touched by the rest of the Police to cover main stream BUDGET overruns.

The Air Support needs to be run by a manager with business sense, exstensive industry knowledge, and enough balls to stand up to idiots like Assistant Commissioner John Standing and his platitudes about subjects he is absolutely ignorant of.

(I'll be kind and suggest maybe he was the poor bunny told to provide a comment..... ill conceived idea, where was the airwings manager, he should have spoken instead)
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Old 5th Jan 2003, 03:44
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Gaunty

Perhaps the point I was trying to make was muddied by my gratuitous (and admittedly unnecessary) shot at Shipwreck.

I just can’t see how, and think it naïve, to consider an operator (as Shipwrek does) as being incapable to operate simple Piston Fixed Wing aircraft then in THE SAME POST consider that very same operator capable of not only operating much more sophisticated equipment (Turbine Rotary) but should have more of them.

My point being, you are either good enough to be an Aviation Operator or not, you can’t be both.

Maybe I am just missing something.
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Old 5th Jan 2003, 03:51
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Gaunty me old....

As much as I respect your opinions, WA does NOT want to take a leaf out of the Qld book.

In Qld, there is the State Govt Air wing - good operators, able aircraft (both of them), and a no-nonsense safety culture. They do not have, nor require, an AOC, which means they cannot partake in aeromed tasks (other than organ retrievals).

There is the RFDS, with no less than 6 disparate centres, all LOOSELY following a central theme in the State. They cannot manage the workload they already have, let alone adding more. I suspect the WA mob would be in the same boat.

There are at least 2 civilian contractors running Qld Health contracts for flying speciallists in the western areas; one of whom I believe has just won a contract to fly a medical speciallist from Mt Isa using a 20 year old C414 (ex Qld Air Ambulance).

There is a Police Airwing, with I dunno what at the moment, aircraft-wise.

There is Qld Emergency Services, with 3 B412s at AF, CN and TV. They also have a hand in running a B412 at Cooly, a AS350 at RK, a Jetranger at BUD, a Longranger at TI, a BK117 at MC, and a Longranger at MK. There's an additional flingwing at CDR which is independantly operated.

There are also assorted ad-hoc CHTR contracts and Standing Offer Arrangements State-wide.

The upshot is, this entire flock of aircraft SHOULD be standardised and amalgamated into ONE State Government-run Air Unit; as should be the case NATIONALLY. ALL Government agencies SHOULD be flying around in the best available equipment - not for ego sake, but for safety (1st) and efficiency (2nd). I refer you to your own postings on this subject, after the C90 crash at TWB last year.

Don't stop at the WA border - this is a NATIONAL issue.

PS: re the Newman prang, from my reading of the report, was he not actually IN the circuit when he lost power? I would like to think that any CPL pilot with a ME endorsement could dead-stick from within the circuit area to at least a survivable crash, if not a power-off landing on the runway. Not being the one in the seat at the time though, like all the other views here, this is only a personal opinion.
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Old 5th Jan 2003, 08:22
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Jamair,

Rolling up a whole lot of Government aviation agencies into one will not necessarily streamline the end product. Flying injured people out of bush strips is vastly different to transporting government ministers. Could you imagine an RFDS pilot wandering back to serve meals in the cabin? And how would you feel about some AIDS infected junkie with manacles travelling in a medical aircraft? Bad enough when they board an RPT and subject the pax to bad language, bad odours and bad behaviour. As I recall the government and police units in QLD amalgamated in the early eighties and split again shortly after because of the incompatibility of the mission profiles of the two organisations.

Governments aren’t cash cows for every new start-up just because it purports to provide a community service. I think the reason why there are so many rotary wing service providers in QLD is due to the independent community funding that they receive which ultimately minimises input by the taxpayer. If the government was expected to fully fund those start-ups I feel the services would be fewer.

Shipreck,

I would have thought fixed wing would be far more viable than rotary in a state the size of WA. However I cannot imagine why organisations like the coppers use old equipment. Do they buy second hand ‘cruisers’ as well? Obviously you are pretty close to the action (a police rotary wing driver perhaps)? Surprising your government hasn’t palmed its rotary operations (as they seem to be rescue related) out to the industry. In any event directing your ideas to the Minister wont always cut it. The separation of powers between the legislative, executive and judicial authorities is such that ministers only approve funding – their heads of departments request it. With that in mind you should direct your talents to the Commissioner.

Jamair, I think the QLD coppers operate a Westwind, a King Air and a Caravan.
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Old 5th Jan 2003, 10:25
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Dragchute

Qld Police operate a Cessna Ultra, a King Air 350 and a couple of Caravans ( I think ).
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Old 5th Jan 2003, 11:29
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megle2

Sounds about right...my info is a bit old. Whatever, they seem to have it together.
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Old 5th Jan 2003, 13:03
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megle2

What you say is correct.

Ultra BN based, King Air 350 and Grand Caravan CS based, with a Caravan based in MA.

The Air Wing has 25+ years of experience with safety being foremost the overriding issue.

Last edited by Black Maria; 5th Jan 2003 at 21:28.
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Old 6th Jan 2003, 07:48
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You got me wrong; I'm not suggesting that the roles be interchangeable, but the ORGANISATION of the operations could or SHOULD be amalgamated. (and the Minister for toe-nail clippings can be just as easily transported via available assets from Police et al as by chartering a 30 yr old PA31). (also, flying an injured patient out of a bush strip should NOT be any different organisationally to flying ministers hither and yon. The same imperatives and restrictions should - MUST - apply. "Can the mission be flown safely, legally and efficiently? Yes = go; No = NO GO. Patient condition, age, situation blah blah blah does not - or SHOULD NOT - enter into the equation.)

I can also categorically GUARANTEE that "AIDS infected junkie" (s) have and do routinely travel in medical aircraft. (& BTW, if you are involved in moving passengers by air, there is a fairly high possibility that you have also moved "AIDS infected junkie" (s) - they don't come with a hazard label.)

It is the ORGANISATION SAFETY CULTURE and mentality that needs to be assured; this can best be done with a single organisational approach. It is the ability of the 'whole of Government' to be able to access aircraft and crews that reflect this suitable SAFETY CULTURE, flying modern aeroplanes, that is vital.

As to the rotary-wing services, having money put in by community groups - laudable as it may be - does not excuse unsuitable aircraft and localised organisations lacking the SAFETY CULTURE that is required to operate these missions. If the missions are there in sufficient numbers to warrant the aircraft, then the aircraft should be a government owned and operated entity, with the SAFETY CULTURE of the best-practice organisations currently functioning. Certainly, community input never goes astray when paying the bills, but it cannot be the governing factor for the operation. Perhaps if the services WERE fewer, they could be better / more efficiently run and coordinated?

I reiterate that Qld is NOT a copybook to look at as the epitome of Government Aerial Operations. Certain parts of it perhaps, some areas definately; but not the whole.

Standardisation - why not? Need a pressurised twin turbine - go the KA200/350, for Aeromed, Executive, Police, General CHTR. Want short / rough field capabilities for aeromed or police ops? then its the C208. Need to be point A to point B in a hurry, executive-wise? The HS125 / Citation Ulta or whatever is the best available product. Gotta get a Chopper? The best available, IFR capable, twin turbine medium lift available, whatever the organisations collectively decide is the best thing. Decide on the fleet, standardise as much as possible across the users, and keep the fleet young. This would HAFTA be a better approach than the usual rag-tag collection.....wouldn't it?

As to the budget issue, if it needs to be done and air is the best way, then the best available should be the standard, not the cheapest available. If the cost makes it non-viable, then it didn't need to be done in the first place.

Cheers.
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Old 20th Jan 2003, 13:17
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Push It Real Good I was going to post an answer to your post, but I realized your are not the brightest crayon in the box. I suggest you read the remainder of the posts and learn something.
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Old 20th Jan 2003, 23:45
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This thread has proved most interesting and it has created some very emotive responses but most of all a healthy cross section of views and opinions.

Considering that the Newman Pilot was not qualified M/E NVFR or IFR I believe it would be fair to say he would have been fairly fatigued after being awake for almost 16 hours & having flown 7 or so hours, of which the 3 hours prior to the crash were in darkness. This is a heavy load for even a very experienced & qualified Pilot. On top of that we don't really know what the stress levels that were imposed on the Pilot from doing his Police duties at the remote community.

Now in the context of the above we consider JAMAIR's comment,

QUOTE:
I would like to think that any CPL pilot with a ME endorsement could dead-stick from within the circuit area to at least a survivable crash, if not a power-off landing on the runway. Not being the one in the seat at the time though, like all the other views here, this is only a personal opinion. (end quote)

I am of the opinion that the Police Pilot did the best he could at the time, with the knowledge and skills he possessed, after all he was not qualified to be flying NVFR.

When both engines quit 3 NM from the runway at a mid down wind position .... at 1000 ' it would be like opening two barn doors, (there goes the glide ratio) add to that the prospect of feathering both engines and consciously committing to a crash landing in dense bush at night,........ in this context I believe all of us would be thinking what are my options???

The Pilot probably thought ... I've got 165 lt of fuel here somewhere, I'll just find it restart the windmilling engines.... and all will be sweet... His head goes down between the seats looking for the fuel taps and the air speed washes off as the nose comes up. We all know the rest.

I agree with Shipreck's comments they are very valid and echo the coroners findings, the Chief Pilot should have been a little more responsible. Gaunty and Push it Real Good also I believe have valid contributions.

Sheep Dog your last post is probably the most colourless posting of all....

Personally I think this Pilot (even though he shouldn't have been flying at the time) would have probably made a much better job of it all had he not been so FATIGUED, after all he had made it that far.
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Old 21st Jan 2003, 01:18
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Vjet

Without casting any aspersions on the chief pilot and operator, who have no doubt gained valuable experience from this unfortunate incident, one must also consider the implications of a double engine failure. Normally both engines don’t fail at the same instant therefore following the initial failure the pilot is faced with a control problem. If he is able to feather and restore control, he is going to be faced with the same problem shortly thereafter. Demanding on even an experienced and physically fresh pilot with the benefit of constant checking and training!

I think the crux of the matter is the fatigue issue. It is often better to stay overnight and attack the task in the cool light of the following day. Having managed a corporate operation where the pilot is given a sophisticated aircraft and a task to perform, much of the further management is left up to the pilot. But operators must stress that the ‘mail does not have to get through’ as many pilots, keen to impress their peers, will push the envelope.
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