Lake Evella crash findings
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Lake Evella crash findings
Lake Evella crash coronor's inquest findings released yesterday.
NT Department of Justice
Interesting reading.
NT Department of Justice
Interesting reading.
Aviation In the Third World
On 4 February 2001 the deceased was the pilot of an aircraft VHBBI a Cessna 210. He was to complete a charter from Lake Evella to Elcho Island on the afternoon of 4 February.
The deceased had never piloted the aircraft known as BBI until he assumed command of it that afternoon
The deceased took control of the aircraft without conducting a pre-flight inspection of it; notwithstanding that Darryl Stace had not completed the daily maintenance report.
Mr Stace had not completed the maintenance release report for the 3rd or the 4th of February. In those circumstances the deceased should have conducted his own check of the aircraft and satisfied himself that there were no outstanding defects so as to render the plane unsafe. Again referring to the stall warning device my understanding is that it can be easily checked whilst on the ground, and whilst in flight provided the checking is done at a safe height.
the deceased did not undertake a normal take-off, rather that he gathered speed quickly and kept the plane low to the runway preparing the aircraft for flight. That is he lifted the undercarriage very close to the ground and probably reached a speed of about 100 knots at the end of the runway before he caused the aircraft to ascend very steeply.
the aircraft climbed very steeply to a height of about 400 - 500 feet, at which stage the aircraft stalled. It then pivoted and descended almost vertically towards the ground albeit that before impact some recovery had taken place.
I am satisfied from the evidence that has been adduced at the inquest that mechanical failure did not contribute to this accident.
no entry had been made in the daily maintenance release relating to BBI that the stall-warning device did not work.
The pilots employed by Air Frontier Pty Ltd at the time of this accident were not paid unless they were flying; and they were paid by the hour to fly. They also received in addition to this hourly flying rate a small retainer, so in the words of Mr Hunt junior "they could survive". It may be that the circumstances of their employment arrangements put pressure on the pilots not to enter defects in planes that they became aware of, particularly those that rendered a plane grounded. It may also be that because the 100-hour service was imminent that the defective stall-warning device was not recorded as defective in the daily maintenance release
The deceased for whatever reason attempted an aerobatic manoeuvre for which he was not trained and for which the aircraft was not designed. Its instrumentation was designed for "normal" flight, not unusual flight. Whether the stall warning device would have sounded during the manoeuvre and whether the deceased would have had time to react to it or not is problematic.
Air Frontier Pty Ltd and their operations were questioned by counsel for the family and both Mr Hunt senior and Mr Hunt junior gave evidence. … Young pilots are employed not within the general aviation award, but on a verbal contract paying them hourly for their flying time. They are expected to live in remote communities in what can only be described as substandard conditions. I do accept that the accommodation at Lake Evella was all that was available, however, that does not make it appropriate.
At the time of this accident the pilots at Lake Evella were young and relatively inexperienced. They had chosen aviation as their respective careers and were flying as much as they could to get up their hours to move on. They were doing their apprenticeship.
Evidence was given at the inquest about a culture of cowboy flying by the "Mooney pilots", as the Air Frontier pilots were known. There was a habit of low flying and the doing of tricks, in fact both Mr Robertson and Mr Stace indicated that they had undertaken aerobatic procedures for which they were not trained. The deceased himself had a reputation for low flying and had told Mr Robertson when he arrived only two weeks before the accident as the newest Air Frontier pilot that "what happens in East Arnhem Land stays in East Arnhem Land". Given that the deceased was the Senior Base pilot at Lake Evella, and to an extent at least responsible for Mr Robertson's training and supervision that evidence is disturbing and corroborative of the cowboy culture.
Air Frontier through its Chief Pilot and Director purported not to know what was going on at Lake Evella and believed that Mr Baxter was performing well. They based this conclusion apparently upon the fact that the accommodation at Lake Evella was neat and tidy whenever the Chief pilot, Mr Hunt visited. All Mr Hunt's visits were scheduled visits, he made no surprise visits so the pilots knew when he was arriving so it is not unusual to expect that they would tidy up their accommodation in anticipation of his visit. No contact was made by Air Frontier with members of the community or anybody else who came in contact with their pilots to check about their conduct and activities. It is difficult to accept that the operators of a charter company in these circumstances would not be aware that young men might, if left to their own devices as these young men were, have some fun and try and extend themselves. Further, given the circumstances in which they were expected to live and work, it is almost beyond belief that they did not know what these pilots were doing. It is clear from the evidence that the pilots knew that what they were doing was wrong, inherently dangerous and not within the charter of their employment or in accordance with their training and knowledge of extant air safety regulations. However, having had the opportunity of seeing Mr Hunt Snr and Jnr give evidence I am inclined to accept that they did not know what their pilots were doing. I note that Mr Hunt Snr is now retired and no longer employed as a Chief Pilot.
… the investigation of this particular accident was made more difficult by the failure of ATSB (Air Transport Safety Bureau) to attend the accident site, at the time, and conduct an investigation. ATSB apparently acting on the advice of others determined that they would not attend the accident because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored as the family may have wished because Mr Heitman the ATSB representative who made that determination was not able to be called to give evidence, because he could not be located. This has deprived the family of the opportunity to test Mr Heitman and ascertain why he formed the view about the accident that he clearly did, without attending the scene or conducting any other enquires[sic] other than telephone contacts with it appears Senior Sergeant Bradley and nobody else. Nonetheless even though Mr Heitman did not give evidence I am comfortable in forming the view that it was an inappropriate and wrong decision and probably not based on any clear direct evidence from any eyewitness to the accident.
It was unfortunate that ATSB did not attend the site of the accident at the time. Notwithstanding I am, as I have indicated, satisfied that a proper investigation did take place and that the circumstances of this accident have been properly and fully investigated. That this happened is largely due to the perseverance of Acting Sergeant Scott Burness, and I commend him for his efforts.
As to how Air Frontier was operating at the time given the circumstances of the Air Operators Certificate and the relationship of Air Frontier Pty Ltd with Mooney Investments/ Mooney Holdings is curious. I will refer the evidence in relation to the status of the company to CASA and invite them to make comment. The issue of the safety of general aviation in the Northern Territory is also a matter that prompts me to forward the transcript of these proceedings to CASA for their information and appropriate action and investigation if necessary. It is beyond the scope of this inquest for me to comment further than I have about the activities of CASA or ATSB or make any findings in relation to them.
The deceased had never piloted the aircraft known as BBI until he assumed command of it that afternoon
The deceased took control of the aircraft without conducting a pre-flight inspection of it; notwithstanding that Darryl Stace had not completed the daily maintenance report.
Mr Stace had not completed the maintenance release report for the 3rd or the 4th of February. In those circumstances the deceased should have conducted his own check of the aircraft and satisfied himself that there were no outstanding defects so as to render the plane unsafe. Again referring to the stall warning device my understanding is that it can be easily checked whilst on the ground, and whilst in flight provided the checking is done at a safe height.
the deceased did not undertake a normal take-off, rather that he gathered speed quickly and kept the plane low to the runway preparing the aircraft for flight. That is he lifted the undercarriage very close to the ground and probably reached a speed of about 100 knots at the end of the runway before he caused the aircraft to ascend very steeply.
the aircraft climbed very steeply to a height of about 400 - 500 feet, at which stage the aircraft stalled. It then pivoted and descended almost vertically towards the ground albeit that before impact some recovery had taken place.
I am satisfied from the evidence that has been adduced at the inquest that mechanical failure did not contribute to this accident.
no entry had been made in the daily maintenance release relating to BBI that the stall-warning device did not work.
The pilots employed by Air Frontier Pty Ltd at the time of this accident were not paid unless they were flying; and they were paid by the hour to fly. They also received in addition to this hourly flying rate a small retainer, so in the words of Mr Hunt junior "they could survive". It may be that the circumstances of their employment arrangements put pressure on the pilots not to enter defects in planes that they became aware of, particularly those that rendered a plane grounded. It may also be that because the 100-hour service was imminent that the defective stall-warning device was not recorded as defective in the daily maintenance release
The deceased for whatever reason attempted an aerobatic manoeuvre for which he was not trained and for which the aircraft was not designed. Its instrumentation was designed for "normal" flight, not unusual flight. Whether the stall warning device would have sounded during the manoeuvre and whether the deceased would have had time to react to it or not is problematic.
Air Frontier Pty Ltd and their operations were questioned by counsel for the family and both Mr Hunt senior and Mr Hunt junior gave evidence. … Young pilots are employed not within the general aviation award, but on a verbal contract paying them hourly for their flying time. They are expected to live in remote communities in what can only be described as substandard conditions. I do accept that the accommodation at Lake Evella was all that was available, however, that does not make it appropriate.
At the time of this accident the pilots at Lake Evella were young and relatively inexperienced. They had chosen aviation as their respective careers and were flying as much as they could to get up their hours to move on. They were doing their apprenticeship.
Evidence was given at the inquest about a culture of cowboy flying by the "Mooney pilots", as the Air Frontier pilots were known. There was a habit of low flying and the doing of tricks, in fact both Mr Robertson and Mr Stace indicated that they had undertaken aerobatic procedures for which they were not trained. The deceased himself had a reputation for low flying and had told Mr Robertson when he arrived only two weeks before the accident as the newest Air Frontier pilot that "what happens in East Arnhem Land stays in East Arnhem Land". Given that the deceased was the Senior Base pilot at Lake Evella, and to an extent at least responsible for Mr Robertson's training and supervision that evidence is disturbing and corroborative of the cowboy culture.
Air Frontier through its Chief Pilot and Director purported not to know what was going on at Lake Evella and believed that Mr Baxter was performing well. They based this conclusion apparently upon the fact that the accommodation at Lake Evella was neat and tidy whenever the Chief pilot, Mr Hunt visited. All Mr Hunt's visits were scheduled visits, he made no surprise visits so the pilots knew when he was arriving so it is not unusual to expect that they would tidy up their accommodation in anticipation of his visit. No contact was made by Air Frontier with members of the community or anybody else who came in contact with their pilots to check about their conduct and activities. It is difficult to accept that the operators of a charter company in these circumstances would not be aware that young men might, if left to their own devices as these young men were, have some fun and try and extend themselves. Further, given the circumstances in which they were expected to live and work, it is almost beyond belief that they did not know what these pilots were doing. It is clear from the evidence that the pilots knew that what they were doing was wrong, inherently dangerous and not within the charter of their employment or in accordance with their training and knowledge of extant air safety regulations. However, having had the opportunity of seeing Mr Hunt Snr and Jnr give evidence I am inclined to accept that they did not know what their pilots were doing. I note that Mr Hunt Snr is now retired and no longer employed as a Chief Pilot.
… the investigation of this particular accident was made more difficult by the failure of ATSB (Air Transport Safety Bureau) to attend the accident site, at the time, and conduct an investigation. ATSB apparently acting on the advice of others determined that they would not attend the accident because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored as the family may have wished because Mr Heitman the ATSB representative who made that determination was not able to be called to give evidence, because he could not be located. This has deprived the family of the opportunity to test Mr Heitman and ascertain why he formed the view about the accident that he clearly did, without attending the scene or conducting any other enquires[sic] other than telephone contacts with it appears Senior Sergeant Bradley and nobody else. Nonetheless even though Mr Heitman did not give evidence I am comfortable in forming the view that it was an inappropriate and wrong decision and probably not based on any clear direct evidence from any eyewitness to the accident.
It was unfortunate that ATSB did not attend the site of the accident at the time. Notwithstanding I am, as I have indicated, satisfied that a proper investigation did take place and that the circumstances of this accident have been properly and fully investigated. That this happened is largely due to the perseverance of Acting Sergeant Scott Burness, and I commend him for his efforts.
As to how Air Frontier was operating at the time given the circumstances of the Air Operators Certificate and the relationship of Air Frontier Pty Ltd with Mooney Investments/ Mooney Holdings is curious. I will refer the evidence in relation to the status of the company to CASA and invite them to make comment. The issue of the safety of general aviation in the Northern Territory is also a matter that prompts me to forward the transcript of these proceedings to CASA for their information and appropriate action and investigation if necessary. It is beyond the scope of this inquest for me to comment further than I have about the activities of CASA or ATSB or make any findings in relation to them.
I cant understand why new pilots from the cities who have spent 30 to 40 grand on getting a license would want to throw it away doing stupid things which has cost this guy his life.
The idea of 'what happens up north stays up north' does not work. Reports like this soon filter down to many places seen as 'the next step' . Do you really think they will employ you?
With such flagerant attitudes it seems some people dont deserve to have a license.
I must admit however nobody deserves to lose their life.
The idea of 'what happens up north stays up north' does not work. Reports like this soon filter down to many places seen as 'the next step' . Do you really think they will employ you?
With such flagerant attitudes it seems some people dont deserve to have a license.
I must admit however nobody deserves to lose their life.
HEALY, I don't think you really realize what goes on up there. The vast majority of this sort of activity does not get reported, at least to anyone who can or will take any action. Because of the remote location(s), reports(generally as pilot gossip) of this kind of activity are usually 7th hand, and unverifiable and I have seen on many occasions it in no way impeeds the particular pilots' progress to the next step at all. Employers cannnot determine the veracity of the 'rumours' they hear and will employ based largely on their own personal impression of the pilot.
Even when 'busted' you can still go to the next stage. Let me give you a well known example from a couple of years back. Pilot x flies metro for well known regional airline in northern Australia. Pilot x gets job with e. coast regional airline. Pilot x, on one of their last RPT flights for current airline, decides to formate with company C402 (both ac full of pax) for a laugh. ha ha ha! Company of course finds out and grounds Pilot x for their last week of employment. BIG DEAL. Pilot x goes on to their job at e. coast regional who either don't know and/or don't care. I give you this example because it is one that was common knowlege, and as Pilot x was an RPT captain, do really think he/she had never done this sort of thing before? Let's face it, there are countless numbers of pilots in all airlines that would like to keep their extra-proffessional activities from earlier days quiet.
So HEALY I think it is fanciful thinking to believe that this activity impeeds a pilots' progress. Why do you think it is that the only time the public hear about this is when there is a death or serious injury?
Even when 'busted' you can still go to the next stage. Let me give you a well known example from a couple of years back. Pilot x flies metro for well known regional airline in northern Australia. Pilot x gets job with e. coast regional airline. Pilot x, on one of their last RPT flights for current airline, decides to formate with company C402 (both ac full of pax) for a laugh. ha ha ha! Company of course finds out and grounds Pilot x for their last week of employment. BIG DEAL. Pilot x goes on to their job at e. coast regional who either don't know and/or don't care. I give you this example because it is one that was common knowlege, and as Pilot x was an RPT captain, do really think he/she had never done this sort of thing before? Let's face it, there are countless numbers of pilots in all airlines that would like to keep their extra-proffessional activities from earlier days quiet.
So HEALY I think it is fanciful thinking to believe that this activity impeeds a pilots' progress. Why do you think it is that the only time the public hear about this is when there is a death or serious injury?
Fair enough SLICE however dont you think it shows even a little bit of unprofessionalism.
Rules are designed to prevent people from ultimately killing themselves or others. Why should it be OK to bend the rules in one place and not the other.
For most the rumours are as you said 7th hand however it could be easy for some pilots to develop a John Wayne mentality which they carry on further into their careers.
As you said in your last paragraph, why should we here of young inexperienced pilots being killed. It just should not happen!
Rules are designed to prevent people from ultimately killing themselves or others. Why should it be OK to bend the rules in one place and not the other.
For most the rumours are as you said 7th hand however it could be easy for some pilots to develop a John Wayne mentality which they carry on further into their careers.
As you said in your last paragraph, why should we here of young inexperienced pilots being killed. It just should not happen!
I agree absolutely - totally unprofessional - but we have face the fact that young men(mostly) when left to their own devices in remote locations will engage in this sort of activity IF they perceive that it will not affect future employment prospects. QF (by no means the only one- but they should set the example) has it ranks embedded with individuals who have a history of doing exactly what the pilot of VH-BBI was doing and worse. QF either don't know or more to the point, don't want to know. Pilots notice this and in absence of any meaningful enforcement of the regulations (CASA) there seems to be little disincentive to becoming an amature test pilot.
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Wow !
What a thread and likewise the Coroners report. Unable to contact the ATSB officer ! The Chief pilot claiming no knowledge of extra professional activities ! Substandard accommodation. Where was CASA while all this was happening ?
Altogether a real can of worms. The retirement of the Chief Pilot can be called convenient but perhaps not beyond the arm of a court action should someone want to follow up on the apparent and knowingly lack of positive control and supervision of the junior pilots at the Lake. Little wonder that the pilots at that location went ferel.
They were underpaid. They lived in sub standard accommodation. They were juniors being exploited in the name of getting flight time to try and better their lives.
There was a major lack of supervision by the CP and not even an experienced, more mature, real senior pilot. One has to say that the firm would not have employed a real senior pilot because it would have cost real money, money that they were apparently not prepared to pay. What is that expression 'You pay peanuts, you get monkeys'?
Reviewing this accident and the Coroners report one has to come to the conclusion that this type of rot is probably going on elsewhere.
One has to ask the question 'What does CASA intend to do about this type of activity'?
One also has to ask serious questions about the involvement or lack of involvement of the ATSB, an organisation that until recently has had the universal respect of the industry. Perhaps no longer.
This writer is of the opinion that a copy of the Coroners report should be forwarded to the CP and owners of all the top end charter firms with the statement that this type of activity stops NOW - no lack of supervision, no pilots allowed to go ferel, no sub standard pay deals and no sub standard accommodation, to name just a few.
In short they will have been warned!
From this point onward those owners and CPs are totally responsible for ensuring that the activities noted above have finished. Period.
Owners and CPs that allow this type of rot to continue are in the gun for legal and financial action. Claiming ignorance will be no excuse !
CASA for one needs to lift its game to ensure that the flying side, at least, is checked and rechecked. Transgressions are to result in the immediate grounding of said firms and the CPs approval cancelled. And the whole dirty mess publicised.
On that subject ALL pilots should be sending a copy of this thread and a copy of the Coroners report to each and every newspaper, big and small, to put the maximum pressure that we can bear onto these two bit firms that could not care a damm about their pilots and their welfare !
Then, and only then, will we see a change in the attitude of some charters firms towards their pilots and their operations in general.
What a thread and likewise the Coroners report. Unable to contact the ATSB officer ! The Chief pilot claiming no knowledge of extra professional activities ! Substandard accommodation. Where was CASA while all this was happening ?
Altogether a real can of worms. The retirement of the Chief Pilot can be called convenient but perhaps not beyond the arm of a court action should someone want to follow up on the apparent and knowingly lack of positive control and supervision of the junior pilots at the Lake. Little wonder that the pilots at that location went ferel.
They were underpaid. They lived in sub standard accommodation. They were juniors being exploited in the name of getting flight time to try and better their lives.
There was a major lack of supervision by the CP and not even an experienced, more mature, real senior pilot. One has to say that the firm would not have employed a real senior pilot because it would have cost real money, money that they were apparently not prepared to pay. What is that expression 'You pay peanuts, you get monkeys'?
Reviewing this accident and the Coroners report one has to come to the conclusion that this type of rot is probably going on elsewhere.
One has to ask the question 'What does CASA intend to do about this type of activity'?
One also has to ask serious questions about the involvement or lack of involvement of the ATSB, an organisation that until recently has had the universal respect of the industry. Perhaps no longer.
This writer is of the opinion that a copy of the Coroners report should be forwarded to the CP and owners of all the top end charter firms with the statement that this type of activity stops NOW - no lack of supervision, no pilots allowed to go ferel, no sub standard pay deals and no sub standard accommodation, to name just a few.
In short they will have been warned!
From this point onward those owners and CPs are totally responsible for ensuring that the activities noted above have finished. Period.
Owners and CPs that allow this type of rot to continue are in the gun for legal and financial action. Claiming ignorance will be no excuse !
CASA for one needs to lift its game to ensure that the flying side, at least, is checked and rechecked. Transgressions are to result in the immediate grounding of said firms and the CPs approval cancelled. And the whole dirty mess publicised.
On that subject ALL pilots should be sending a copy of this thread and a copy of the Coroners report to each and every newspaper, big and small, to put the maximum pressure that we can bear onto these two bit firms that could not care a damm about their pilots and their welfare !
Then, and only then, will we see a change in the attitude of some charters firms towards their pilots and their operations in general.
CurtissJenny
I agree with you totally. The only problem I think you will find is that CASA doesn’t have the power to control pilot’s wages or accommodation issues. One could argue that it is a proper and adequate rest issue but I am not certain if CAO 48 covers this. I could be wrong, as it is a while since I have had anything to do with Australia’s Flight and Duty regs.
I agree with you totally. The only problem I think you will find is that CASA doesn’t have the power to control pilot’s wages or accommodation issues. One could argue that it is a proper and adequate rest issue but I am not certain if CAO 48 covers this. I could be wrong, as it is a while since I have had anything to do with Australia’s Flight and Duty regs.
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404 Titan,
Thanks for the follow up.
I am of the view that this accident and the Coroners report marks a watershed in how pilots, young pilots in particular, should be employed and treated while flying charter in the top end, or anywhere for that matter.
If we as pilots do not take a stand now this kind of exploitation will continue while there are young pilots out there prepared to accept sub-standard conditions in the name of getting a few hours to take them on the next and hopefully better flight position.
If we do nothing then CPs and employers will take that as acceptance of conditions that they would not put up with if applied to themselves.
I say again to ALL pilots forward a copy of this entire thread, with the Coroners report marked in highlighter, to every newspaper that you can find - big and small - with the view that the adverse publicity will stop this kind of rot.
Those sub standard CPs and employers need to be informed that they are on notice that this kind of activity is not acceptable and that they have been warned.
A repeat should be grounds for court action and a financial penalty.
Thanks for the follow up.
I am of the view that this accident and the Coroners report marks a watershed in how pilots, young pilots in particular, should be employed and treated while flying charter in the top end, or anywhere for that matter.
If we as pilots do not take a stand now this kind of exploitation will continue while there are young pilots out there prepared to accept sub-standard conditions in the name of getting a few hours to take them on the next and hopefully better flight position.
If we do nothing then CPs and employers will take that as acceptance of conditions that they would not put up with if applied to themselves.
I say again to ALL pilots forward a copy of this entire thread, with the Coroners report marked in highlighter, to every newspaper that you can find - big and small - with the view that the adverse publicity will stop this kind of rot.
Those sub standard CPs and employers need to be informed that they are on notice that this kind of activity is not acceptable and that they have been warned.
A repeat should be grounds for court action and a financial penalty.
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Firstly I want to say that I think it is tragic that that a young man died for what was a rush blood, a silly moment. I hear that he was one of the least likely to do this sort of thing though I may be wrong. My heart sunk as I read the report, it really shocked me. What went though his mind moments before the impact with the ground. I bet you he said "why did I do it, what for?". And his parents, what can I say.. there are no words for them. Having said this, I and most others have had the odd rush of blood. Mine have been quite boring and legal really, and in reality, I find just flying enough of a rush. Whenever I think about this sort of thing, I think back to this man or another not long ago in the NT and think what would they and their families give to turn back time. It takes discipline to fly high performance GA singles and twins on a ferry when mates are watching, I know. But unlike impressing your mates with your bmx back when you were 10 this is a different ball game. I'm constantly reminding myself and others about these young men who are up there looking down on us wishing they had another chance. Do me and everyone else a favour and condemn the "horseplay" before we read again about a mother who has lost their baby or mate who has lost his best mate. Its just not on. Mr. Hat.
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There was a major lack of supervision by the CP and not even an experienced, more mature, real senior pilot. One has to say that the firm would not have employed a real senior pilot because it would have cost real money, money that they were apparently not prepared to pay. What is that expression 'You pay peanuts, you get monkeys'?
Is this wrong? How old should you be? How many hours? Are you realistically going to find ANY pilot that could be considered "senior" that would WANT to go live in Lake Evella flying locals around in C210's and C206's? Not bloody likely.
From this point onward those owners and CPs are totally responsible for ensuring that the activities noted above have finished. Period.
A hypothetical situation if you will, lets say a report comes onto the chief pilots desk from another employee or other company pilot that they suspect that Joe Bloggs at Kickatinalong is doing some low flying or the occasional beat up. Chief pilot takes the pilot in, gives him a verbal thrashing and him them on the spot. With no evidence (and lets face it, most pilots wouldn't be willing to give evidence against a collegue) I wonder how quickly the company ends up in court for unfair dismissal.
I totally agree that there need to be systems in place to minimise the number of accidents that do occur. Better education, better training, closer supervision and more accountability will all help, but you will never prevent situations like these from happening again.
There is alot that this report has said, and yes, it is time for something to be done about it. It will take time and effort on the behalf of the regulator, the operator, the insurer and the pilot.
Well said Mr Hat.
It brings forward an idea which has probably been thrown around alot but, to my knowledge (correct me if wrong) failed to materialise. An independant Pilot Union which can prevent such exploitation.
This idea, which get many people laughing however could help prevent such occurances. It seems the pressures put on many pilots are through a number of different factors.
The idea of such a Union for GA I guess can not be seen as realistic with so many pilots willing to work for sod all to get that elusive experience.
It is very easy to look at a situation and say "yeah, it will be OK" however this is a good time to take stock and really think if it is actually worth it. It would be even better in such a situation as the victim found himself in to fly it as it should be flown correctly and obey all Legal and Airmanship qualities which could wash off on his mates and prevent their parents getting a phone call.
Food for thought.
It brings forward an idea which has probably been thrown around alot but, to my knowledge (correct me if wrong) failed to materialise. An independant Pilot Union which can prevent such exploitation.
This idea, which get many people laughing however could help prevent such occurances. It seems the pressures put on many pilots are through a number of different factors.
The idea of such a Union for GA I guess can not be seen as realistic with so many pilots willing to work for sod all to get that elusive experience.
It is very easy to look at a situation and say "yeah, it will be OK" however this is a good time to take stock and really think if it is actually worth it. It would be even better in such a situation as the victim found himself in to fly it as it should be flown correctly and obey all Legal and Airmanship qualities which could wash off on his mates and prevent their parents getting a phone call.
Food for thought.
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Unfortunately Mr Hat, the culture still exists, as demonstrated by the similar accident at Groote.
It comes back to the culture set by the CP and the company. It is to easy for those at the top to say they were unaware of what was happening at the out bases.
Slice reports on an incident with a regional in NT, and it would appear when made aware of the incident, took positive action, as such a incident was not part of their culture.
I can recall the regional in Tasmania where the CP actively encouraged low flying, and from all reports, was the ring leader in flying 4 engine piston aircraft along beaches at 50'.
Numerous other episodes from around Aust spring to mind, and I would say that there are a few senior Captains out there who are saying "but for the grace of God go I".
The other sad thing is that when these accidents happen, the first thing we read about is how good the pilot was, what a beaut person they were, what a good pilot etc etc. The Coroners report or ATSB report usually indicates a gross error.
CASA need to become more than a paper tiger, and get out into the industry push the Safety case from a practical point of view. Operators who are not supervising their pilot's activities should be forced to pay the penalty with automatic suspension of their AOC.
It comes back to the culture set by the CP and the company. It is to easy for those at the top to say they were unaware of what was happening at the out bases.
Slice reports on an incident with a regional in NT, and it would appear when made aware of the incident, took positive action, as such a incident was not part of their culture.
I can recall the regional in Tasmania where the CP actively encouraged low flying, and from all reports, was the ring leader in flying 4 engine piston aircraft along beaches at 50'.
Numerous other episodes from around Aust spring to mind, and I would say that there are a few senior Captains out there who are saying "but for the grace of God go I".
The other sad thing is that when these accidents happen, the first thing we read about is how good the pilot was, what a beaut person they were, what a good pilot etc etc. The Coroners report or ATSB report usually indicates a gross error.
CASA need to become more than a paper tiger, and get out into the industry push the Safety case from a practical point of view. Operators who are not supervising their pilot's activities should be forced to pay the penalty with automatic suspension of their AOC.
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Check the facts
Before taking a swipe at the ATSB, I suggest contributors and coroners check the legislation under which it works. Essentially it does a safety investigation only. It does NOT apportion blame. The Director can choose NOT to investigate if he or she so decides. If the ATSB finds, or if there is a suggestion that an accident, was due pilot culpibility and there is no safety benefit from the investigation, it will drop the investigation or simply not investigate...that is CASA's job in that instance and it is up to CASA to investigate if so chooses.
In the past, BASI investigated every accident. Goverment has chosen to cut funding to the agency and so the ATSB has had to choose which accidents/incidents it investigates due to financial/resource limitations. That choice is often made on the initial report. Coroners have taken to giving the ATSB a hard time about investigations because they had come to rely on the ATSB (BASI ) to do their job for them. The sooner Coroners and the like realise that the ATSB does not work for them, and that they have a responsibility to conduct their own thorough investigations, the better it will be for all.
So here, it seems, we have a classic busting of rules, and limits, and an extremely poor display of airmanship (read common sense). The ATSB chose not to investigate. That is it, close the book. So what do we learn from this accident? Being a cowboy eventually catches up with you? Follow the rules? Wow, no new lesson in that one!
In the past, BASI investigated every accident. Goverment has chosen to cut funding to the agency and so the ATSB has had to choose which accidents/incidents it investigates due to financial/resource limitations. That choice is often made on the initial report. Coroners have taken to giving the ATSB a hard time about investigations because they had come to rely on the ATSB (BASI ) to do their job for them. The sooner Coroners and the like realise that the ATSB does not work for them, and that they have a responsibility to conduct their own thorough investigations, the better it will be for all.
So here, it seems, we have a classic busting of rules, and limits, and an extremely poor display of airmanship (read common sense). The ATSB chose not to investigate. That is it, close the book. So what do we learn from this accident? Being a cowboy eventually catches up with you? Follow the rules? Wow, no new lesson in that one!
A company from the directors and chief pilot down must instill a culture that fosters a mature a disciplined attitude from all. If this also means dismissal for some actions then so be it. There are such companies out there. It is a shame they all can’t be like that.
Owners and Chief Pilots have had some onerous responsibilities for a long time. Those responsibilities include:
They appear to have been neither complied with nor enforced in this case.
One of more flagrant breaches of section 28BE that I’ve seen for a while.
SPLATR – sadly true. That was the point of my post. “Senior Base Pilots” busting the rules and dying in commercial operations, against a backdrop of no supervision or regulation, is apparently now such a mundane event in Australian aviation that the investigator doesn’t bother turning up.
Civil Aviation Act section 28BE - Duty to exercise care and diligence
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of its directors must also take the steps specified in subsection (1).
(3) It is evidence of a failure by a body and its directors to comply with this section if an act covered by this section is done without a reasonable degree of care and diligence mainly because of:
(a) inadequate corporate management, control or supervision of the conduct of any of the body's directors, servants or agents; or
(b) failure to provide adequate systems for communicating relevant information to relevant people in the body.
CAO 82.0 Appendix 1 - 2 RESPONSIBILITIES OF CHIEF PILOT
2.1 The Chief Pilot for an operator is to have control of all flight crew training and operational matters affecting the safety of the flying operations of the operator.
2.2 The responsibilities of a Chief Pilot must, unless CASA otherwise specifies in writing, include the following responsibilities:
(a) ensuring that the operator’s air operations are conducted in compliance with the Act, the Civil Aviation Regulations 1988, the Civil Aviation Regulations 1998 and the Civil Aviation Orders;
…
(f) monitoring operational standards, maintaining training records and supervising the training and checking of flight crew of the operator;
…
(1) The holder of an AOC must at all times take all reasonable steps to ensure that every activity covered by the AOC, and everything done in connection with such an activity, is done with a reasonable degree of care and diligence.
(2) If the holder is a body having legal personality, each of its directors must also take the steps specified in subsection (1).
(3) It is evidence of a failure by a body and its directors to comply with this section if an act covered by this section is done without a reasonable degree of care and diligence mainly because of:
(a) inadequate corporate management, control or supervision of the conduct of any of the body's directors, servants or agents; or
(b) failure to provide adequate systems for communicating relevant information to relevant people in the body.
CAO 82.0 Appendix 1 - 2 RESPONSIBILITIES OF CHIEF PILOT
2.1 The Chief Pilot for an operator is to have control of all flight crew training and operational matters affecting the safety of the flying operations of the operator.
2.2 The responsibilities of a Chief Pilot must, unless CASA otherwise specifies in writing, include the following responsibilities:
(a) ensuring that the operator’s air operations are conducted in compliance with the Act, the Civil Aviation Regulations 1988, the Civil Aviation Regulations 1998 and the Civil Aviation Orders;
…
(f) monitoring operational standards, maintaining training records and supervising the training and checking of flight crew of the operator;
…
having had the opportunity of seeing Mr Hunt Snr and Jnr give evidence I am inclined to accept that they did not know what their pilots were doing.
SPLATR – sadly true. That was the point of my post. “Senior Base Pilots” busting the rules and dying in commercial operations, against a backdrop of no supervision or regulation, is apparently now such a mundane event in Australian aviation that the investigator doesn’t bother turning up.
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Chief Pilots are not able to stop people from doing stupid things, the accident happened due to the fact a young pilot did something stupid and killed himself.
As a Chief Pilot you have to assert yourself but ultimately a person with a CPL should know what can happen from such a stupid action, does a Chief Pilot need to brief him\her specifically on not to do this even though CASA has made the effort to make it LAW.
The coroner did a great job.
Not all GA companies can afford to operate brand new kingairs and provide pilots with 60K package, these pilots are at the early stages of an apprenticeship, therefore crap wages and a large learning curve.
As a Chief Pilot you have to assert yourself but ultimately a person with a CPL should know what can happen from such a stupid action, does a Chief Pilot need to brief him\her specifically on not to do this even though CASA has made the effort to make it LAW.
The coroner did a great job.
Not all GA companies can afford to operate brand new kingairs and provide pilots with 60K package, these pilots are at the early stages of an apprenticeship, therefore crap wages and a large learning curve.
Lefthanded_Rock_Thrower
You may be very right when you say that a Chief Pilot may not be able to stop people from doing stupid things, but they will be held responsible for them. From what has been written in the Coroner’s report there was a severe lack of supervision of operations at this companies remote bases. Accusations have also been made in the report that the pilot concerned and other pilots had been known to do this type of thing before.
I don’t know this company and its reputation because I never operated out of Darwin, but isn’t it a shame that this company appears to have had a reputation amongst other individuals and companies. I certainly knew which companies had a good reputation when I worked in FNQ a number of years ago. They all instilled a culture of professionalism and maturity. New pilots were selected not only on their experience but also on their attitude, something that was lacking in many a hopeful new pilot I interviewed. From our companies point of view it was made very clear at the interview and in their contract that any breach of the CAO’s, ANO’s and SOP’s could lead to instant dismissal.
You may be very right when you say that a Chief Pilot may not be able to stop people from doing stupid things, but they will be held responsible for them. From what has been written in the Coroner’s report there was a severe lack of supervision of operations at this companies remote bases. Accusations have also been made in the report that the pilot concerned and other pilots had been known to do this type of thing before.
Evidence was given at the inquest about a culture of cowboy flying by the "Mooney pilots", as the Air Frontier pilots were known. There was a habit of low flying and the doing of tricks, in fact both Mr Robertson and Mr Stace indicated that they had undertaken aerobatic procedures for which they were not trained. The deceased himself had a reputation for low flying and had told Mr Robertson when he arrived only two weeks before the accident as the newest Air Frontier pilot that "what happens in East Arnhem Land stays in East Arnhem Land". Given that the deceased was the Senior Base pilot at Lake Evella, and to an extent at least responsible for Mr Robertson's training and supervision that evidence is disturbing and corroborative of the cowboy culture.
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404 Titan as usual spot on.
BUT.
Geeeeeeeez, and , here I go again, VH-BBI (unless the rego has been transferred to anothery) was a very tired old sh!tfight the last time I saw her over 15 years ago and I dont imagine she has been sitting in a hangar since and must have put on at least another 9,000 hrs. Which BTW was about its design life in the first place.
I cant find the serial number because VH-BBI is now a Bell 206 but if my memory serves me right it must have been an early "M"
and by then with probably a min. 15,000 hrs.??
I don't suppose any one looked beyond the "stupid pilot" routine, as it appears that the ATSB did not attend the site, and investigate the very real possibility of a structural or component failure at some time during the final seconds, given the age and service conditions of that aircraft.
The youngster may have been a little enthusiastic and I am not condoning the alleged actions, but the manoeuvre described may well have been performed within the airframe design limits, but was simply the straw that broke the camels back.
Prof Reason may have something to say about the whole hapenstance.
Young pilots and geriatric airframes do not mix well.
But I guess that now, we'll never know.
BUT.
Geeeeeeeez, and , here I go again, VH-BBI (unless the rego has been transferred to anothery) was a very tired old sh!tfight the last time I saw her over 15 years ago and I dont imagine she has been sitting in a hangar since and must have put on at least another 9,000 hrs. Which BTW was about its design life in the first place.
I cant find the serial number because VH-BBI is now a Bell 206 but if my memory serves me right it must have been an early "M"
and by then with probably a min. 15,000 hrs.??
I don't suppose any one looked beyond the "stupid pilot" routine, as it appears that the ATSB did not attend the site, and investigate the very real possibility of a structural or component failure at some time during the final seconds, given the age and service conditions of that aircraft.
The youngster may have been a little enthusiastic and I am not condoning the alleged actions, but the manoeuvre described may well have been performed within the airframe design limits, but was simply the straw that broke the camels back.
is apparently now such a mundane event in Australian aviation that the investigator doesn’t bother turning up.
Young pilots and geriatric airframes do not mix well.
But I guess that now, we'll never know.
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404 Titan, in all respects I agree, although ( theres always an although ) alot of the "Evidence" can possibly be categorized as scuttlebutt, as no person was willing to actually state times and locations alot in legally left unproven.
at face value it would appear that this these pilots had infact gone feral, we've all seen them.
so with that it leaves CASA with only the subjective to react to, it looks like ****, it smells like **** and yep, it tastes like ****, it therefore must be.
if the persons feeding the scuttlebutt fire would come forward alteast these sort of things could be headed off.
at face value it would appear that this these pilots had infact gone feral, we've all seen them.
so with that it leaves CASA with only the subjective to react to, it looks like ****, it smells like **** and yep, it tastes like ****, it therefore must be.
if the persons feeding the scuttlebutt fire would come forward alteast these sort of things could be headed off.