Lockhart River Coroners Findings (Merged)
 

:(
http://www.justice.qld.gov.au/courts...0findings1.pdf

Read it and weep!

Quite an extraordinary preamble w.r.t. the CASA / ATSB conflict! Worth perusing as well as the main part of the report.

And from this side of the Tasman the similarities between the coroners findings of this "accident" and the Chieftain "accident" at Christchurch certainly makes the observation "Read it and weep" very relevant.

Well having read the whole things there are some terms such as “Systemic Bias” which is tragic.
To me it seems that given all the pointers, going all the way back to ’99 and the gent that went to the ATSB who was referred to CASA, the holes in the swiss cheese had been forming for a long time.

As an outsider looking in, it appears that the event was only a matter of time.

What gives me insight, I was a Chief Pilot of a turbine operator in FNQ, and approved under CAR 217 just like these fellas but I have to say that the inspection of our operation by Tony M, Peter Mac & Bill Mc were a lot more rigorous.

Having operated over the same terrain I understand intimately the weather and the operational requirements. (Think trying to explain to an owner why going to HID I needed Weipa as an alternate - crews not yet endorsed for DGA), outside their cost model someone once said.

The final insult to me is that the plane cost half of what the investigation cost:ugh:

The report indicates that the whole thing was completely avoidable. Tragic.:uhoh:

From memory, "Mr Ian Harvey" wrote the CASA report. :eek:

Good to see that things are on a level playing field :{

Casa/atsb
 

Just read the Coroners report on the Lochart River accident and wonder what his comments have to say about the regulatory authorities. Are things really as bad as he hints, and more importantly what is/are the problem/s?

CASA had senior, expert legal representation who I’m sure would not have made such a sustained attack on the integrity of the ATSB investigation report without explicit instructions. In my view, these protestations are symptomatic of serious, ongoing animosity between the two organisations that needs redressing. I shall return to the issue in the recommendation section of these findings.

Interaction between the ATSB and CASA
Finally, I wish to return to the concerns I expressed earlier about the working relationship between CASA and the ATSB. In this and previous inquests I have detected a degree of animosity that I consider inimical to a productive, collaborative focus on air safety. CASA’s submissions in this inquest suggest there was a danger of the ATSB’s recommendations being ignored and I continue to detect a defensive and less than fulsome response to some of them. I am aware that others in the aviation industry share these concerns, although I anticipate the CEO’s of the two agencies will disavow them.

Seems to be a total disconnect with CASA's view of aviation safety and reality when the they put forth "CASA submitted that responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash." The sort of statement you would expect to see written by a know nothing tabloid journalist, not a body entrusted with the regulation and safety of the industry. I'm sure they have even met James Reason, or is that an unreasonable assumption?

Well Hello...??? Lockhart, Anybody??
 

I'm really surprised that no-one has reacted to the coroner's findings on Lockhart.

Putting aside the expected 'prime suspects', why wasn't CASA singled out for specific condemnation - and legal action......

Try
 

Fascinating
 

Interesting that this thread has been moved to D&G General Aviation & Questions the place for students, instructors and charter guys rather than being left on D & G Reporting Points Airline and RPT issues in Australia and enZed. I thought this Aerotropics flight operated by Transair was RPT.

Interesting that people promote Reason and come up with one major cause for the accident. No aviation safety regulator has the hand of God to stop accidents. Look at the road kills around Australia.

Interesting that no one is considering the responsibilities of the operator. He owned and operated the company. The containment of risk was his primary responsibility.

Interesting that no one is being reflective on the pilot in command responsibilities.

Interesting that none of the 'informed' members of the industry had the gumption to put their concerns formally before the accident.
Interesting that the ATSB report in relation to the pilots actions was discredited by the Coroner. Where is the professional analysis of the report in the context of the Coroner's findings.

Possibly the moderator has got it right, this thread lacks sufficient depth to remain on the D&G Reporting Points site.:(

Frank Burden - I have to whole heartedly agree with you

Maybe because of post #9 :p

Page 53 of the Coroners report (bolding mine)

Having read parts of the Coroner's Report I feel that some of his conculsions are based on legalities rather than practicalities.

For example he appears to dismiss the First Officer's ability to influence the approach as he was not qualified to conduct a GPS NPA. I don't find this credible. I am not qualified to do a GPS approach but I can sure read and interpret the approach plate as I am sure most IFR qualified pilots can do.

The Coroner also seems to be saying that the Captain was attempting to get visual based on comments made to an inquest concerning a previous fatal crash. This is despite the fact that the Lockart River R12 approach is over high ground. If the approach had been made from the opposite direction then the comment may have had more validity.

The prospect of a lack of situational awareness is given scant attention.

However, the Coroner's conclusions, quoted by Brian Abraham, would appear correct. The handling pilot's performance in the past and apparently on the day was less than professional. It was a crash waiting to happen. The CASA oversight program is a joke. It gives lip service to compliance of the regulations by only doing paper audits. They serve to absolve CASA of any responsibility for when things go pear shaped, they most certainly do not detect actual non-compliance. The company is now no longer but it also appears to have been less than satisfactory in its running of its operations. The chickens appear to have come home to roost.

Will aviation learn from this crash. Probably not. It most certainly learnt nothing from Seaview, Monarch and Whyalla. Why should this one be any different? Let's just blame someone else.:mad:

A simple question for the more knowledgeable and experienced here....

I note previous threads, some years old, about the standards and behaviours of certain North Queensland CASA staff (only known by their nicknames, such as "Pinocchio"), all of whom have apparently now departed in the face of the "New Broom" - BB.

May I ask if certain of these gentlemen were responsible for auditing Transair?

OK I'm going to get absolutely burned alive here however, was I the only person that was surprised by the shear volume of spelling, grammatical and formatting errors in what is supposed to be a rather important and official report? Sorry for the drift and just delete this if its too out of line.

Good Question Fishy,

As an RPT operator in FNQ we were supervised by the Brisbane “RPT/High Capacity” FOI’s not by TSV staff.

We were however ramp checked by TSV staff who demonstrated their complete lack of knowledge of turbine aircraft on more than one occasion.:mad: :\

Licences, Medicals, Loadsheets, manuals…… no problem;). Turbine aircraft and higher caliber systems….. forget it:ugh::{

I would be very surprised if they (TSV) had inspection accreditation of the Transair group. :E

Page 37 of the Coroners Report States that the pilots had not been "Cleared to Line".Please Excuse me if Im abit naive but I've never worked for a company in charter or RPT (and thats been a few)that have not conducted a rigorous check to line with plenty of paper work filled out at the end of it.
If this is the case then certain people with in the company and CASA do have a very serious case to answer.

Regards The Dog

To the contrary Mr Burden, I find nothing trivial about Australia’s worst scheduled air service accident in 30 years.

The thread was started in this forum and a parallel thread started later in Reporting Points, was merged with this thread. I’m happy to move the thread to Reporting Points if you think it will make one iota difference to the lessons we should learn from this tragic event?

I too read the Coroner’s Report and am mystified that certain important regulatory and operational issues upon which one would expect the Coroner to investigate or at least comment, fail to rate a mention in the Report.

Seven people perished in the June 1993 Monarch Airlines Piper Chieftain crash at Young, NSW, nine people perished in the October 1994 Seaview Commander 690B disappearance enroute to Lord Howe and eight people perished in the May 2000 Whyalla Airlines Piper Chieftain disappearance into Spencer Gulf, all three accidents being extensively investigated (including numerous and extensive formal inquiries) and important lessons were learned.

And yet fifteen people tragically and needlessly died at Lockhart River in the worst air disaster in thirty years and we are to learn nothing except the cause was “pilot error” and CASA and the ATSB don’t always cooperate?

No Mr Burden, the Lockhart River accident was not trivial. I’m not sure I could make the same comment regarding the Coroner’s findings. Indeed, one could be excused for feeling the legal profession and perhaps even certain politicians got the report they sought.

I can assure you that CASA's TL office have recently taken some huge strides towards cleaning up the cowboy GA operators in NQ - NOT.:bored::bored::bored:

Dr :cool:

FTDK. Are you referring to those employed within the CASA FNQ offices, or FNQ GA operators in general?

Aside from the odd immovable geriatric, I agree almost all CASA FNQ staff have changed in the past few years.

Surveillance of the AOC holder involved in the Lockhart River accident emanated from the CASA Airline Office in Brisbane - not the CASA offices at TL or CS.

Tail Wheel

Check you PMs, your right on!:ok::E

Sadness
 

A chain of events which ended with the deaths of innocent parties. There is a lot in this. I won't point a finger at anyone specific, rather a group of people, organisations, regulators and individuals who should have known better! If each party allows irregularities to go uncorrected then disaster is the ultimate outcome. It could have all been avoided.

Flight HC675
 

Tailwheel

You are correct.

When the circumstances of the inquiries into Monarch, Seaview and Whyalla are compared to flight HC675 at Lockhart River,
one can be excused for contemplating that something is not quite right.

When one digs deeper and investigates how this inquest has been stage managed,
the sheer co-incidence of counsel assisting with a vested commercial interest in things CASA,
with tentacles reaching into the upper echelons of CASA, conveniently recently retired, and other matters of public interest,
one cannot feel a little disturbed.

The accident and fatality rate in FNQ was and is out of proportion to the rest of Australia, despite an attempt by ATSB to dismiss that.

There is no doubt that the TL & CS CASA offices may have somehow failed,
not looking where they should have,
and looking and harassing where they shouldn't have.

Yes, there is no doubt that were human factors attributable to the crew that caused this tragedy.

What is overlooked is the lack of effective surveillance that created the climate that permitted the culture to grow and flourish.

The causes for the lack of effective surveillance result from several areas,
some similarities to Seaview with mates rates deals,
and the failure of the NQAO to conduct surveillance on another jurisdictions turf.

There is more substance for a Royal Commission into flight HC675 than there was for Seaview, but the wagons were circled early in the investigation.

There is no political will for an RC, the Federal Govt cannot afford the exposure in a lead up to an election.

We have all witnessed a whitewash of Watergate dimensions.

Its over, and swept under the carpet.

There have been further career casualties as a result, but they too have been kept relatively quiet.

What more can I say?

Recommending charges against the operator may well have also necessitated the Coroner taking a far more detailed look at the role played by CASA staff?

Fifteen people needlessly die; no lessons to be learned to avoid similar disasters in the future; and justice has not seen to be done by the families who lost loved ones.

Frankly I dont give a STUFF whether the operator is charged or not. That won't make one iota of difference to safety.

How many more operators are there out there like this one? Could CASA answer that question? I think not. It would seem they have no idea.

How many more accidents like this have to happen before something is done to improve CASA? They appear to be toothless and useless as far as giving the travelling public any confidence at all in their safety.

Then we have a Coroners hearing in which counsel assisting has (seemingly) a close relationship with CASA. I was not in the least suprised by this outcome. Extremely disappointed - but not suprised.

I don't think the families will be letting it go at that though. Stay tuned!

Di :mad:

:rolleyes:I learned very early in my career not to "buck the system" nor will you ever "beat the establishment". There will always be too many aces held in the wrong palms.
The beat goes on.

Anger over crash ruling

Courier Mail
August 18 – 19, 2007.

Angry scenes erupted outside a Brisbane Courthouse yesterday after the State Coroner delivered his inquest findings into the Lockhart River plane crash in which 15 people died.

It was the nations worst air disaster in almost 40 years, the two man flight crew and their 13 passengers died when the Transair operated aircraft slammed into a hillside about 11 kms northwest of the Lockhart River aerodrome on May 7, 2005.

Among the dead were David Banks 55, Frank Billy 21, Fred Bowie 25, Mardie Bowie 30, Robert Brady 35, Edward Green 35, Kenneth Hurst 55, Gordon Kris 37, Noel lewis 48, Paul Norris 34, Arden Sonter 44, Sally Urquhart 28 and Helen Woosup 25.

During the delivery of his lengthy findings, State Coroner Michael Barnes upset some family members by saying he would not make anyone a scapegoat for the crash, despite identifying failings by Transair and levelling criticisms at the Civil Aviation Safety Authority.

“With all due respect to those families, the making of scape goats in that manner is not part of my function,” he said.

“I find that CASA could have done more to insist that Transair improve certain aspects of its operations but I do not believe the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash.”

Outside the court, Trad Thornton – the fiancée of Constable Sally Urquhart – said he thought the scapegoat comment was “absolutely ridiculous”.

“We’re looking for answers and were hoping that Mr Barnes would make numerous recommendations to stop something like this from happening again,” he said.

Constable Urquhart’s father, Shane, said that CASA had got away scott-free and described the inquest outcome asa “whole waste of time”.

Mr Barnes made four recommendations, including that CASA expedite the introduction of mandatory crew resource management training.

He also called for CASA to reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations.

He also asked the Federal Minister for Transport address “a degree of animosity” between CASA abd the Australian Transport Safety Bureau.

I would suggest that the Regulator & the Industry take a long hard look at the value of " Stabilised Approaches " as against any type of "scud running" in RPT operations.

Oh, I see. Thanks.

I thought that was what the Coroner was expected to consider? :confused:

Frustrating!!!!
 

So where to now?

The pilot was at fault, he is dead.

The operator is clearly negligent, he has disappeared overseas.
Don't blame him, if my loved ones had perished on that plane, I would hunt the bastard down and put him out of his f:mad:cken misery.

CASA were negligent, what the hell will they do now that will make a difference? I can tell you.....F:mad:CK ALL.

Attention Regulators. How about doing something that makes a
f:mad:cking difference. What will be done to ensure that this doesn't happen again? What have we learned from this that we can implement to improve the safety of the travelling public?

The weather at LHR was a factor. So why doesn't it have an AWIS with a ceiliometer?? Oh that's right because its expensive.

If you have tried this approach in a strong SE wind you will know about the horrendous turbulence. Is there a warning on the approach plate of this? Nah that would be to sensible, let the suckers find out for themselves.

What f:mad:cken idiot designed the approach in the first place? Probably the same one who penned the CKN NDB to go directly over the highest hill in the area. What the f:mad:ck do you expect to happen??

A TRAGIC UNNECESSARY LOSS OF LIFE.:{


200

So True" TWO HUNDRED"

Fifteen lives can be lost and no one is made accountable,but If for some reason you ripped of the TAX office you would find yourself in Gaol very quickly.So the old rule applies that money is worth more than life.

Regards The Dog

CRIKEY!!!

(from Crikey.com)
CASA couldn't stop Transair, so what good are they?

Date: Monday, 20 August 2007

Ben Sandilands writes:

It would have been appropriate for air sickness bags to have been handed out to the relatives of those killed in the Lockhart River air crash when Queensland coroner Michael Barnes reported his finding on the disaster on Friday afternoon.
Barnes blamed the deaths of 13 passengers and both pilots on 7 May 2005 on the actions of the senior pilot Brett Hotchin and the defunct regional carrier Transair.

An astonishing revelation really. Just as the Australian Transport Safety Bureau made clinically clear in its ferocious report into the accident published in April.

Also astonishing is the finding that CASA could not have prevented the crash.

If it couldn’t prevent even a tin pot airline serving Aboriginal and Torres Strait Islander communities from crashing, why is CASA being trusted with the safety regulation of big Australian airlines?

Can someone, perhaps the Minister of Transport Mark Vaile, discover at what threshold of air transport activity CASA becomes effective?

Before the Coroner sat, CASA had admitted knowing that Transair was deficient in key operational matters. It knew that pilot Brett Hotchins was dangerous.

Yet it told the public nothing about what it knew, knowledge that might have informed decisions about whether to fly on its services. Its oversight of its operations was so ineffective it let Transair masquerade as a safe airline and fly 13 unsuspecting passengers to their deaths.

What else isn’t CASA telling us? How many dead people will it take for the government to address the core issues of culture and competency and resources in air transport safety regulation for all Australians, black, white, outback, city, in large jets or small turbo-props?

Surely Ian Harvey QC, the counsel assisting the coroner must have tried his utmost to focus the inquest on issues that go to the core of public safety in the air?

After all, he came to the inquiry with impeccable credentials in terms of insights into aviation and CASA, having earned $475,436 from appearing for the safety regulator between July 1, 2002 and June 30, 2006.



Di :(

Di

Maybe I am naive and out of the loop here, but does the last part of that story suggest......A CONFLICT OF INTEREST there?:uhoh:

If so that needs running up a flag pole!

SQ

Of course not Squawk! He achieved exactly what his client expected!

Squawk,

Spot on mate.

You too AA.

The coroner really should have had someone assisting who had no connection with any of the parties involved - just to remove any doubt.

Di

I actually went to the Brisbane Coroners Court for a number of days and watched procedings.
During my time there I only saw two others who were not involved as legal advisors, press ect.
One I understand was an ex Transair pilot viewing procedings from another room via video. That was on the day the Chief Pilot was in the box. The other, who knows.
I was impressed with the Coroner. His report was well written and reflected what I witnessed.
Its a pity that basically nobody from the industry bothered to attend.

More from Crikey
 

Lest we forget,

17. Senate questions over CASA crash and burn
Ben Sandilands writes:

There is a very bad smell hanging over conduct of CASA in relation to safety oversight of Transair, the now defunct remote community airline that killed 15 people in the Lockhart River crash of 7 May 2005.

Crikey has examined more than 100 serious and detailed questions raised in the Senate by Senators Kerry O’Brien and Jan McLucas before and after the Australian Transport Safety Bureau released its scathing final report into the disaster on 4 April.

Every single one of them received a pro forma brush off response from Senator David Johnston representing the Minister for Transport, Mark Vaile, with each response including these paragraphs:

The accident is also currently being examined in an inquest by the Queensland Coroner's Office.

Both CASA and the ATSB are assisting the Coroner. The coronial inquest provides the most appropriate forum for detailed and objective consideration of CASA’s oversight of Transair.

Together, the ATSB report, the coronial proceedings, and the evidence CASA has provided to the Senate on several occasions, ensure that the public interest in the issues raised by the accident is fully addressed.

These formula answers were being churned out by Senator Johnston and put on the parliamentary record right up to day the Queensland Coroner, Michael Barnes, delivered his report on 17 August.

Clearly the Minister’s confidence in "detailed and objective" consideration is misplaced and he must be as disappointed in the Coroner as everyone else.

The Coroner, ably assisted by none other than Ian Harvey QC, who often represents the safety regulator in legal matters, scarcely touches upon voluminous matters of concern to the relatives of the victims.

Or the wider interests of air travellers exposed to CASA’s failings in relation to its safety obligations to remote and predominantly Aboriginal community air services which remain unresolved.

The Senate, in however much time it has left, is the only place in which these answers can be pursued.

Some of the questions are very pertinent and technical, and were clearly framed after receiving detailed advice about the specific actions and inactions that must have transpired between CASA and Transair over a period of time.

Is it all too hard for the Minister and the safety regulator to confront the truth, that between 1999 and the fatal day, all of the processes and checks the CASA claimed to have in place where sometimes not performed, or continually bungled?

Or is it a case that the airline and its victims are dead, and best forgotten?

Lockhart River Inquest lawyer replies

Date: Friday, 24 August 2007

Ian Harvey QC, counsel to the Coroner in the Lockhart River Inquest, writes:

The good fortune of Crikey’s readership in having the intrepid Ben Sandilands as its aviation writer has been demonstrated once more with his in-depth reporting of the recently concluded Lockhart River Inquest.
With more than 45 years in journalism, Ben Sandilands is an internationally respected travel writer who over the years has produced incisive articles on a range of aviation topics for "prominent media". He no doubt has earned 100’s of thousands of dollars over recent years writing for "syndication arms" and "leading newspapers" around the world.

Surely with such a wealth of experience in addition to pouring over transcripts of Parliamentary Committee proceedings, he must have tried his utmost to come to grips with almost 2000 pages of transcript, some 170 exhibits and an array of other documents produced at the inquest to inform himself on the core issues on aviation safety that were examined.

With these "impeccable credentials" in terms of insights into aviation and an understanding of the aetiology of accidents, I only wish that Ben Sandilands could apply those skills to all aviation matters in the passionate pursuit - that we all share - of ensuring public safety in aviation. Indeed one accident comes specifically to mind.

It is almost the 20th anniversary of a controlled flight into terrain accident by a Fokker F27 aircraft of Burma Airways on approach to Pagan. All 49 people on board the aircraft were killed. The reasons for the accident have never really been explained. A journalist colleague of Ben Sandilands was actually awaiting the arrival of the aircraft at Pagan.
Fate was kind to him but without the impeccable credentials of a Ben Sandilands I don’t think he conducted any kind of forensic investigation of why a perfectly good aircraft flew into a mountain. I mean, if getting information out of Australian aviation authorities is hard, imagine the frustrating difficulty of extracting anything from the Burmese government.
However, with the international reputation and respect that Mr Sandilands commands, I am sure he could get to the real reasons for that accident.

Oh, and why, I can hear Ben Sandilands ask, do I specifically mention a CFIT accident of twenty years ago? I suppose it’s just that my father and step-mother were two of four Australians on board that flight.


WHAT'S THIS ALL ABOUT? Surely this is not actually Ian Harvey writing this? What's he trying to say? You would think he might have taken the opportunity to defend his reputation rather than slagging off at the journalist?

Di :sad:

Maybe he is a little closer to the facts than the Journalist?

Di

Perhaps that's Ian's way of saying that he's the last person on the planet who has any interest in covering up the real causes of CFIT accidents (I use 'accidents' in the counter-intuitive, ICAO sense).

You did notice the bit about his father and step-mother having died in an as-yet unexplained CFIT accident, didn't you?

And won't the coroner be impressed at the insult to his intelligence! The truth was there to be discovered, but that tricky lawyer managed to cover it up.

Lockhart River Inquest
 

This is my last post on this subject.

Undisputed fact:

CFIT due to deviation from SOP’s (established from evidence).

i.e. not utilising stabilised approach, one crew member not qualified for the approach, both crew members not completed CRM course as per Ops Manual Sect C.

Substantiated history of non compliance in various areas.

OK, yes, Pilot Error, close the case.

Coroner’s duty:

Establish cause of death of victims.
Who was killed
When did it happen
Where did it happen
How did it happen
Why did it happen
Make recommendations to mitigate re- occurrence
Coroner’s duty completed.

But wait! What created the culture that it was ok to not comply?

Why was the operator reasonably sure that it was ok not to ensure it followed its Ops Manual?

Why was a pilot rostered for a flight without all the boxes in the C & T being ticked and signed off?

Shouldn’t the non compliances have been picked up in a normal everyday CASA audit?

Ben Sandilands merely pointed out the more than 100 questions asked in the Senate (and thus available on Hansard) about the diligence of the regulator,
and the evasive and possibly untruthful answers given as to the role of the regulator.

The senate was assured that not only had CASA conducted an audit on the operator,
CASA actually stated that it was a “Fulsome Audit”. (Hansard)

Subsequently ATSB established just how deficient that “fulsome audit” was, and listed the numerous deficient areas.

On the basis of Hansard and ATSB, there may be evidence to suggest that the regulator didn’t in fact regulate the particular operator in a diligent and impartial manner,

and thus maybe a contributory factor in the accident that had to happen, eventually happening.

The appointment of a CASA loyal Counsel Assisting caused consternation and objections were raised by families of the deceased.

Those objections were over ruled.

Outcome: Pilot Error, case closed on Australia’s worst aviation tragedy in 30 + years.

This tragedy eclipsed Seaview, Monarch and Whyalla, but was simply better stage managed.

The damage control was very effective, but it was noted that while there were some animosities between CASA and the ATSB, there were no contributory deficiencies.

Lest We Forget

Excellent post Mainframe.

It is now highly likely that that is the end of the matter as far as aviation safety in Australia is concerned. Nothing will change. We must now wait for the next major accident, or perhaps another 2 or 3 - or 10 - before perhaps something is done to improve CASA's effectiveness.

The only other hope is action taken by the relatives left behind. This may take many forms, and may require assistance from our friends the lawyers and journalists - and may or may not have any effect.

Perhaps the fact that there is a looming federal election can be used to apply pressure?

At the end of the day it seems "Best We Forget" rather than "Lest We Forget".

Di :{