VH-PGW PA-31P-350 15 June 2010 Crash Investigation
 

http://www.atsb.gov.au/media/1576030...043_prelim.pdf

The Australian Transport Safety Bureau (ATSB) today released the preliminary factual report into the 15 June 2010 aircraft accident that killed a pilot and a flight nurse in Canley Vale, NSW.The report presents the facts of the accident gathered by the ATSB's initial investigation.
The investigation is continuing.

The ATSB will examine the recovered aircraft components, maintenance records and operational issues. Investigators will also review the operator's flight crew training records and conduct further analysis on the air traffic control radar and voice recordings.

A final report is expected to be released within 12 months of the accident.

The preliminary report tells nothing new. However it's a fair call to say that if the pilot had elected to land at Richmond they may not have reached the crash site.

I guess back to the old adage "Get the plane on the ground ASAP"

I really hope that the ATSB is able to find the mechanical problems with this aircraft.

From the data shown the pilot had this aircraft in an approx. 1,000'/min descent which would seem to indicate that he was trying to get back on the ground in a hurry. If correct, it again raises the question of "why not Richmond?"

PLovett & 1a sound asleep

Why not Richmond? Maybe because it was considered unsuitable by the PIC.

From the preliminary report:

YSRI RWY 28 ILS
Performance Cat A&B
DA = 360ft + PEC 50ft = 410ft, Vis = 1.2 km (forcast QNH)
DA = 307ft + PEC 50ft = 357ft, Vis = 0.8 km (actual QNH)

All depends what "shallow fog" means in this context. The correct definition is " low-lying fog that does not obstruct horizontal visibility at a level 2 m (6 ft) or more above the surface of the earth." In other words it is less than 2m deep, possibly less than 1m deep. Hardly a good reason to pass the runway by, particularly as the runway would have been clearly visible from altitude through such a thin layer.

The fact that vertical visibility info was unavailable tells you that the fog layer was not deep enough to cover the sensor.

My feeling is the report may suggest that the pilot felt the need/duty/desire to return to Bankstown. Whether this is a real or perceived commercial pressure is another issue. In the real world nobody wants a bent a/c in their log book - whether it was your fault or not. Maybe that's something in aviation culture that needs changing. Certainly there are airlines that will not employ a pilot with any accident history, irrespective of the cause/outcome:(

The old saying ":sad:the second engine in a piston will only carry you to the crash site" somehow seems to fade after a few thousand twin hours.

In some ways it's not fair to critic what happened. BUT, I know everybody learns from investigations and I do hope there's a lesson in this at the end of the day

remoak

The problem is that the horizontal visibility was 300 metres at ground level up to 2 metres and 800 metres visibility is required from the Cat 1 DA of 357 ft with an actual QNH all the way down to the runway. Having experienced this type of fog in Anchorage a number of times and conducting auto lands off all of them, I wouldn’t recommend trying to manually land in these types of conditions unless your ass was on fire because of the insidious way the lack of horizontal visibility creeps up on you at the last minute. Unfortunately from what I gathered from the preliminary report I doubt the PIC realised his ass was on fire until it was far too late.

He should have declared atleast a pan call and stated he is drifting down on 1 engine at vyse, rather than descending rapidly to low altitudes to conform with ATC and being overconfident that his machine will have the desired performance when reaching his descent altitude.

1a sound asleep
I’ll leave that comment for others to debate, but suffice to say it is a myth and is certainly so regarding this case. The aircraft is certified to be able to maintain 5000 ft on one engine at MTOW in ISA conditions. On the day it was 11°C colder and 21hPa higher pressure than ISA and well below MTOW.

100.above

And how have you deduced this from the preliminary report?

Exactly. And the kind of debate currently going on YSRI vs YSBK and why was what got this thread shut down last time...

There is only one person who knows why a return to BK was attempted, and everything else we can postulate here is a guess at best.

I am sure at the time that he thought the best course of action was BK. And i more than likely would have too. More facts (cause of initial failure, power available on remaining engine, A/C not having available height/airspeed/power to get off the back of the drag curve) are required before jumping to conclusions.

RatsoreA
Actually it does. We now know for certain where he was, what height he was at when he turned back, times, ROD, speeds, weather (forecast and actual), RT etc. All before was purely speculative at best and that is the reason it was closed down.

404 Titan
 

Well, yes, and no! :} And I am not suggesting this be shut down either.

It confirms what most were able to deduce with the little info we had previously. Yes, it certainly clears up the Wx/route/ROD/etc etc.

But I don't think a lot of those (newly highlighted and confirmed??!) facts weren't in contention on this forum.


Disclaimer - Just my opinion!

Could we PLEASE not have the idiot posts in this thread that resulted in the other one being locked.

I didn't know Andrew (or Kathy) but I hope that through the actions taken by Andrew this thread can be used so that we can all learn something and not end up with the same tragic result.

Why was the aircraft descending at such a rate? I do not know the PA31 but the ROD seems excessive.
Do you think the pilot may have been complying with ATC "instructions" and deliberately descended rather than "drift down" and maintain a height advantage?
0752:12 - ATC instructed the pilot to maintain 5,000 feet.
0754:35 - Soon after, ATC instructed the pilot to descend to 2,500 ft and advised that Richmond airport was two miles to the south of the aircraft if the pilot could not maintain height. The pilot advised that the aircraft was on a ‘slow descent’. At this time, the aircraft was descending through 4,700 ft with a groundspeed of 163 kts.
[I bolded the above]

• Is 1,000 fpm considered a slow descent in this aircraft with one engine out?
• Is the height lost during the turn back to Bankstown a reasonable amount to be expected during this time? (Engine checks, shutdown, secure engine etc)
• What is the Blue Line speed on the PA31?
• Several witnesses reported hearing a ‘spluttering’ engine sound. Could this spluttering sound have been caused by the throttle being closed for the landing? (keeping in mind that spluttering to us can mean something quite different to non aviators) Again I do not know this aircraft and how it behaves.

I am still wondering why unsuspecting NSW Health patients are being transported by 30-odd year old light piston-powered twins, when NSW Ambulance (a division of NSW Health) has contracted RFDS with near-new twin-turbine Kingairs sitting at Sydney for that exact task.....?

The busted-arse old Chieftain etc might do the job cheaper, but what is the cost when something like this happens?

There's plenty of "should haves" in life. This poor little bugger didn't live to regret his.

You mean like this one -

Jamair

The aircraft in question might have been 26 years old but it only had 6000 odd hours on the airframe. I wouldn’t call that busted arse. It probably had fewer hours on it than the average RFDS aircraft.

404 Titan wrote:

Despite the fact that the process under which those aircraft were issued their Type Certification was conducted in excess of thirty plus years ago those airframes are getting very tired now, it very blatantly highlights that some other issue was in play at the time - one that may not have come to light yet.

Like many, I've had my own issues with Pa-31s, mine was minor compared to the one that took the life of Andrew and Karen, but it still struggled even with partial power on the bad one at near MTOW, and that was many, many years ago.

It would be interesting to see just how many aircraft retain their original certified performance these days, and in fact I feel it should be mandatory as part of CASA's ageing aircraft program for each effected airframe to have to re-demonstrate its continued compliance with its original certification standards in order to be re-issed an annual/MR.

RatsoreA, Jamair makes a very valid point. In this day and age there is no place for piston powered dung heaps in Government sponsored/paid for operations, to think otherwise is rather indicative of a Flat Earth mentality.

Canley Vale plane crash
 

I have been following the developments in this crash as I was one of the witnesses who saw the plane when it first developed problems over Wilberforce and have a copy of the report released today. I don't have pilot or plane knowledge, but have some basic mechanical knowledge due to my line of work and observed things that I can't pinpoint or find answers for. Is it permissable for me to ask questions here to try and understand further what happened at my end?

RatsoreA

I think many folk here would think that the post by Jamair has quite a lot of merrit. Unlike yours!

Despite the "shallow fog" and it must have been pretty light, others were doing ILS practice there just prior, what I have learned from this is, in a sick running single, or a engine out twin piston, take the ILS below you, be slightly high on the GS, and hold a stable approach even if its a very shallow fog, because a mostly in control touch down on a large wide runway trumps tracking over suburban Sydney every day.

Note to the above comment: in the case of an engine failing from an unknown fault (i.e may be fuel related for example, rather than oil up the cowls from a broken crank or rod), you need to assume that your remaining engine may not be a sure thing. If its a genuine engine failure and you are 100% sure the other will do the job, then fair enough. It is fair to say in this case neither these two points were clear cut.

No doubt some here will argue this.........

J:ok:

Breeze01

Ask away, there will be a lot of folk here willing to help with good knowlege of the plane type concerned.

The debates that get going here will be interesting all the same!

Being the one who alerted Jamair to the fact that these operations were being conducted, I am also asking questions of NSW Health as to WHY patients were being carried in these old aircraft, with "inexperienced" (in comparison to your average RFDS pilot) pilots flying, with no choice in the matter nor the facts, ie. You are not as safe in this aircraft, as you are in an Air Ambulance (RFDS) aircraft.

404, please think before opening mouth. This is a very very valid question that needs to be looked at following this accident.

morno

Removed due to my having been falsely accused of being associated with media.

404 Titan

Utter the word "mayday" and that requirement goes out the window.

At the point that the wheels would have touched the runway, the pilot's eyes would have been well above 2m, so you point is pedantic at best - he would never have entered the shallow fog, only his undercarriage would have. The only consideration is slant vis, but with what was obviously radiation fog that was rapidly burning off, and a reported vis of 300m, there is no doubt at all that runway markings and lights would have been visible through the layer.

I have also had extensive experience of fog (in the UK, the home of fog), and the shallow stuff is generally not a problem. It's the stuff that forms in a layer 200-300 feet thick that will get you.

I agree remoak...

the only word I haven't heard mentioned to date is "mayday...mayday...mayday..."

Les Norton
Define tired? Is it how old it is or how many hours on the airframe or a combination of both? A 26 year old airframe with only 6000 hours is well within the manufacturer’s tolerance of an airframes life cycle.

I’ve had three engine failures in light twins in my time and without exception they all performed as the manufacturer quoted in the POH. One of the aircraft (a BN2 with 10 POB) in PNG had 22k on the airframe and the others had 10k+. All occurred in the tropics in ISA+10-15 conditions.

morno

Define “inexperienced” or did you me “less experienced”. I could make the same derogatory comment to you but I won’t because it detracts from the debate at hand. For the record I actually don’t have a problem with Jamair’s post. I do have a problem with people labelling all piston twins as junk when that’s quite clearly not the case.

remoak

That can be debated until the cows come home and we would never reach a consensus here. My personal opinion is a Pan Pan call is generally more appropriate with an engine shutdown in a twin rather than a May Day call.

It is the PIC’s decision as to the relative suitability of an aerodrome for a division after an in-flight engine shut down. My guess is the PIC, considering the nature of the problem at the time decided BK was more suitable. This was probably reinforced by the fact he had just departed from there and knew the actual weather and the forecast for RIC was average and was also probably substantiated by what he saw outside his window.

Hindsight is a wonderful thing and I’m sure if the PIC had the chance to do it over again he would probably and I would hope do things differently. I think we all need to put ourselves in his shoes and imagine for a minute how we would have handled the situation knowing what he knew at the time rather than what we know now.

As for the shallow fog debate, let’s just agree to disagree. My experience has been that just as I’m flaring the visibility deteriorates substantially to the point it can be dangerous. Remember we are talking about fog here not mist and all that it entails with regards to horizontal visibility.

Bl@@dy good call. :ok:

Finally, some sense.

Facts and logic please.
 

There was something seriously wrong with this aircraft, or it's pilot. We do not yet know what.
This was not a Chieftain, it was a Mojave, and it was pressurised, and capable of maintaining about 15,000 ft with one engine inoperative. It had apparently flown only about 5,000 hours. Many of our airliners have flown about ten times that, or more. Many Chieftains have also flown much more than that. And also RFDS PC12's. The The NT Airmed Kingairs for the new top end contract are also "old".
I am saddened to see that some posts on here appear to to criticise the integrity of the operation, (dung heap etc) and by association, the people involved.
We must wait for more information before making any such statements.

Its not about the age of the aircraft but the hours it has on the airframe etc and the maintenance it has had.. i liken it to a 3 yr old cab with 400000k's on the clock.....

Blue line in the Mojave is 101kts.

G'Day Breeze,

What was your question?

And you may wish to consider that if you are a witness providing some 'official input' to ATSB into the enquiry, you may wish to retain your 'uncontaminated' recall of your interpretations and simply keep what you already have, fresh in your mind, as you may/may not - get 'sidetracked' here by some answers which may/may not be 'correct'........

Not all respondents are experts, IMHO........

Best Regards:ok:

Whatever, it doesn't really matter. A PAN is more correct but either will immediately remove any requirement for the PIC to observe any rule or procedure, which is the point I was making.

Yes I think we all agree on that, the main debate is over whether you should EVER abandon a perfectly good runway underneath you for a more convenient one some distance away. I don't think that you should, simply because if you go for the one beneath you, the chances or crashing are very close to zero. If you go for the distant runway... you might make it, you might not. Why risk it? There is really only one answer to that question, and we all know what it is... and it starts with a "c"...

My point is that it shouldn't even be a question of that. Prudence demands that you take the SAFEST POSSIBLE course of action AT ALL TIMES. If you always do that, none of this stuff ever needs to be discussed, and two people would be alive right now.

Mist is a complete no-brainer. Fog might be an issue if the vis was, say 50m, but it wasn't, it was 300m. You should be able to get a Mojave stopped in 300mm without too many problems. So what exactly is the issue? Even if - and it's a big if - you were to lose visual reference as you touched down, what is the worst that could happen? As opposed to what actually did happen in this accident? Even just watching the HSI should be enough to slow down safely without leaving the runway at Richmond... and that would only be necessary if you lost all visual reference... which simply won't happen in those conditions.

I've been watching this topic fairly closely, and have resisted the urge to comment, mostly out of sensitivity to those involved. Hopefully what I have to say will not be constriued as "having a go", because that is sincerely not my intention.

I grew up not 500 metres from the crash site. I did nearly 10 years in G/A (mostly out of Bankstown), and accumilated about 1600 hours in PA31 aircraft with several operators. I can tell you now, I feel so sad about this whole episode that I almost want to cry!

As stated in the report, other information may come to light, and there for the grace of God..., but whether to land at RIC or not to land at RIC, IMHO appears to be a moot point. WHY, WHY, WHY, did the pilot sacrifice invaluable altitude rather than adopt a drift-down. I know it's easy to be an armchair critic, but I've had failures in PA31's and was taught early on: Initial actions, blue-line, power to maintain min ROD, declare a PAN, take stock. After the initial shock, that should reasonably take no longer than a minute, in that time he lost over 1200 feet!

I think it can be said that the pilot probably didn't realise the lack of performance available untill after his rapid (in anybody's language) descent from over 7000 feet down to 1500 feet at 12 miles BK! If he had taken stock, ie: ROD at blue-line with max power available on the "good" engine, he just may have discovered a "curve-ball" with at least some altitude to spare.

Engine failures, even in ageing G/A aircraft are still relatively rare, and perhaps there lies part of the problem. I now have the benefit of between 6-8 engine failures a year, both at altitude (failure management and performance/decision making), and EFATO's, (critical handling/performance/decision making) conducted over 4 sim sessions twice a year. Even so when it happens for real the initial reaction is usually "holy sh!te!" It's what you do subsequently of course that makes the difference.

I hope for the sake of the families and friends, and the wider aviation community, that some of the questions are eventually answered. As is the way with these things, maybe some changes to the way people are trained might help reduce the risks in the future.

WHile there were points during the return to Bankstown where the aircraft descended at or close to 1000 fpm, for the most part the rate was more like 700 fpm, and after 3000' the rate slowed to 500fpm and then 300 fpm.

To my mind this indicates that the pilot was initially descending at a 'normal' rate towards 2500', with power in the 'good' engine reduced for the descent, and under a mistaken belief that power would be available to hold 2500' or descend as required slowly to 1000' prior to final once the airfield was in sight.

A perfectly normal and understandable response to an engine out in a relatively high performance twin. The aircraft failed to respond when asked for the expected power from the 'good' engine, and to my mind that must be considered to be the primary cause of this unfortunate accident.

Agreed Krusty

On the last thread I posted a youtube video of the Thompsonfly 757....no sooner had it happend it was a MAYDAY and they were give whatever airspace they wanted.

Same could have happened here. If he still had enough performance from one engine to do better than blue line and not lose height, it would have been far better to do BK at 7000 approx and orbit in. ATC would have given it to him.

I see the report says filled with AVGAS, I wonder does this really rule out kero in the fuel?

My point exactly nojwod. The aircraft I currently fly has far superior One Engine Inoperative performance to the Mojave, but if we lose an engine we Always adopt a driftdown with max continuous power on the "good" one. If we arrive over our intended point of landing at a much higher altitude than normal, then great. It's money in the bank.

Gidday Jaba'. I've only heard third hand that several other aircraft were filled from the same source without incident. Some-one in the know might be able to confirm however?

I saw that too Jaba. I imagine that that was specifically put in there to clarify that this was not a case of the wrong fuel.

Of course I could be wrong but it does make sense.

For the ATCOs: What is the SOP for this scenario with respect to altitudes? If the pilot's not declared a PAN or MAYDAY do you still have to direct a descent if otherwise required (i.e. airspace you've no control over or priority traffic). (I say priority traffic as no emergency was declared in the case of my question.)

Anyway, lesson learnt. With a loss of performance maintain what you've got. Maybe an exception would be in IMC and upon spotting a hole good enough for a visual approach.

FRQ CB

For those attacking the decision not to utilise Richmond, I would have most likely made the same decision. As such, I feel the denigration of those who cannot defend themselves is not righteous.

Granted I have very little local or type knowledge, though fog and fog are different animals. Conditions reported (though with best intentions), are often highly variable, with changes by the minute rather large at times.

I would not like to arrive in a marginal, committed situation, only to find nothing visible. So many times I have been wrong in my expectations with fog, it simply is an animal that commands respect. I do not enjoy playing with it, even with options.

The media reports today, reading far to much into the inital reports make me sick. You ignorant headline grabbing bastards.

We are not attacking anyone not here to defend themselves. Questioning decissions maybe but none of us are calling him a reckless fool.

No none of us would, but precission approach, in a controlled manner V crowded suburban streets, power/phone/cable TV wires everywhere at 200kph....NO WAY!

As for whatever the Media are doing.....why would you be surprised? You did sum that up quite well indeed :ok:

The Mojave is a great aircraft, just a little heavy. There is only one reason why the Mojave would not maintain height on one engine and that is if the operating engine was "sick". The pilot possibly guesstimated that he could reach YSBK on his descent.....he miscalculated, gee he was only 3nm from the threshold. he lost a lot of height in the turn which he couldn't regain.

Fog viz....well its bloody hard to land in fog, those that have had to be there understand where i am coming from. Landing in fog with a sick aircraft against the calculated chance of returning to and reaching base......it was his call. If the poor bugger had made it, there wouldn't be a post on here, but he didn't. A command decision with the cards stacked against you both ways.... is a very difficult one.