That's interesting. Never knew it was available. It begs the question why the ATSB did not include a screen shot. This shows NIL rain in the area at the time of the accident. Which is consistent with the Horsham METAR detailed in the preliminary report, but omitted from the final report.

The inimitable Sarcs – Post 73 ATSB – has provided some of the answers. Comparing the very different 'grasping the nettle' approach taken by TC/TSB as opposed to the week kneed, technical waffle, broken promises and ass covering tactics used by our lot.

One burning question is how many little smoking holes equal one bigun; add the numbers. We have buried enough the past 12- 18 months to fill a regional airliner. Do we have a problem ? – Oh yes, I believe we do.

There is a clearly defined, (by grave markers) ancient case for examining IMC/VMC related accidents, there is subtle but important 'mind set' factor which needs be addressed. The requirement for 'instrument' flight training is mandated, why?, well for one, so that an inadvertent excursion into cloud can be managed, for another, so that when caught out on a dark and stormy a 'rough but safe' short passage 'on the clocks' can be managed.

(Q) is it safer to hold MSA on the clocks and depart the fix or; try and scud run it home ?. The question is it operationally safe and 'illegal'; or, is it 'legal' but operationally unsound is begging answers. Is fear of mother earth less than the fear of having your life made a living hell for a short accidental (or necessary) IMC excursion?.

Can't fly on the clocks for five minutes? – go learn, go practice, do 10 minutes in every hour on the dials – it may, one day just save your hide – if the gods choose to spare you....

There's a whole 'nother can of worms Kharon - you'll have the "don't tell them about sex or they'll all want to do it" pundits loading up both barrels.

The one thing I did want to raise though was the bit about having your life made a living hell for an inadvertant IMC excursion, does anyone have first hand experience of tea and bikkies after such an incident? Reason I ask is I did the old ATNS tour a while ago and had a recording of exactly that played. In the discussion afterward, the point was made that there was no sanction, a written please explain and that was the end of it. Was he just lucky or is this the general approach to pilots who 'fess up early in the piece?

I think that a limitation of the radar is that it can't see below the horizon. The further away from it you are, the more likely it is that rain could be below the radar horizon.

I have been rained on with nothing showing on the radar a lot closer to Melbourne than that. It means that the rain is coming from low cloud...

I wonder how many NVFR pilots out there that got their ratings perhaps last year, let alone 20 years ago that could survive if you put a blanket over their windscreen after takeoff to fly 50 miles to to an unfamilar airport and take the blanket off at 5 miles to run with only runway lights visible on a DARK night.

It's currently legal for a NVFR to fly in these conditions.... is it not?

ABC + Wallup for starters.

This is a terrible tragic accident and I offer my condolences to those effected in any way by this event.

I don't mean to be callous or disrespectful in any way however to me this accident was totally avoidable simply by following the most basic of all rules and asking (as a pilot) the one question that has been ingrained in all of us repeatedly (like at every operational licencing or endorsement test, BFR or whatever) over the years.

Q. "Can I legally fly this aircraft if it doesn't have a current maintenance release?"

I think everyone knows the answer to that question.

Sorry,

Stiky.
:(

As much as this sounds bad and as illegal as it may be, being 9 hours over on the MR it's not something that they have highlighted in detail as contributing.

Look closely at the MR and you'll see that is has the validity of the MR with an "OR" on it; that is by date OR by hours. This is for the "annual inspection." If the maintenance schedule / manufacturer allows for it, you can do more than 100 hours in the calendar year. Pilots and owners should stop calling it the "100 hourly" as technically it's an "annual inspection."

These 2 cases are at completely different ends of the spectrum. I've flown in the area surrounding Woomera at night on a regular basis and an outback at night is a completely different kettle of fish. Indeed I was in William Creek a day or so after the ABC report was released and discussed it with Pilotette, who commented that she would not have liked to have flown that night. In the instance of the ABC chopper there would have been some light reference in the sky (stars) but absolutely nothing on the ground. In this instance there would have been no light reference in the sky whatsover (due to cloud), but some ground lights visible.

I landed at Tullaramine in a kero burner shortly before the accident and recall thinking that the weather behind the front was a lot better than I expected with very good visibility (as generally happens after rain). Melbourne is a fair distance from the accident site, but I recall that the front had passed and the weather was improving. My guess is that there was no rain at the time (supported by the weather radar and the Horsham METAR that is shown in the prelim report but absent from the final report). My guess is that the visibility was good (ie clean air) but with fading light. It should be noted that last light occurs later at altitude, so it would have seemed a little better in the air. The accident occurred less than 10 minutes after sunset and about 10 minutes before theoretical last light. The flight was also into the setting sun, which helps prolong light a little also.

Despite having access to altitude information from both GPS and Transponder returns, the ATSB report makes no mention at all about cruising altitudes. The ATSB report has a discussion about the track LSALT (it says 2100 ft) but is completely mute about the aircraft's altitude. The only mention of altitude at all is a vague report from a witness that the aircraft was low. Based on the report, for all we know the aircraft may have been cruising above the LSALT up until the accident. However it should be noted that despite the track LSALT of 2100 ft the aircraft could have successfully made it to Nhil, Horsham or Warracknabeal at 200 ft AGL from the crash location. The area of the crash is as flat as the proverbial hat.

My guess is that at the area of the accident, the lights of Horsham (18 nm), Dimboola (7nm), Warracknabeal (12nm), Jeparit (18nm) and even potentially Nhill (27nm) would have been visible. If there was a cloudbase, then probably there was light reflection from the cloud as well as direct light. If the Horsham PAL had been activated, you'd just about see the runway. There were probably also a number of small towns with a couple of lights within 10 nm, including: Antwerp, Murra Warra, Kellac, Wallop, Canum, plus farm lights and probably some traffic on the highway beneath. One might have considered that a reference flight for comparison in the area on a similar night might have been possible sometime in the 2 years and 4 months that this report took to write.

There has been a lot of discussion about disorientation from looking down to a tablet PC on the pilots lap. I have heard 3rd hand that it was an ipad and that a yoke mount had been installed for it the day prior. This changes the impression of the situation a bit. Once again, one might have thought that this was worthy of note by the ATSB.

This is a pilot who had a 1.5 hour NVMC check flight with an instructor in a similar remote rural area a month beforehand. Together with an established NVMC rating and experience (even if limited) over several years, something is wrong with the licencing and check system if he couldn't maintain control 10 minutes after sunset.

By comparison, the potential that he was trying to deal with a passenger whose nervousness was documented and whom had unbuckled her seatbelt is not discussed at all. Isn't it possible that the passenger became agitated and that contributed to the pilots erratic heading control, erratic altitude control and erratic airspeed control?

I'm not trying to defend the pilot who has clearly made a number of errors of judgment. Nor am I trying to shift blame to the passenger. My point is against the ATSB who (again) have delivered an incomplete report, without any primary data, with areas of conflict with facts presented in the preliminary report and inconsistencies in the report itself. We deserve better - we are certainly paying for it. This is a report that has cost us probably more than $200,000.

Good point. In fact it is possible to run to a Piper 150 hour / 12 month schedule.

Its also interesting to note that the ATSB wording is very vague. Their wording might also apply to it being 9 hours over a 50 hour oil change. A proper report would table the actual hours (ie show primary data).

None of the Mildura, Mt Gambier or Melbourne radars show rain the in Warracknabeal / Nhil / Horsham Area. I take the point, but if nothing paints on any of the 3 surrounding radars, its hard to believe there was significant rain at the time. Especially since the Horsham METAR backs this up. Clearly it was a pretty bad day with earlier rain, but its rain at the time that counts.

a lot of light rain in the Sydney basin wont get picked up by the radars at terry Hills, Wollongong, or Kurnell.

as the front passed last night, the radar return was showing heavy rain along the entire Sydney coast, just off the shoreline. yet there was no significant cloud in sight.

Atmospheric conditions can play some funny tricks with radar returns.

Agreed- but 3 triangulating radars and one with line of sight to the location?

My experience is that rain with nothing showing on the radar is quite common. It is usually drizzle from low cloud.

From the BOM web site information on radar:

All 3 radar sites are around 200km or more away from the area in question. They are borderline for coverage in that area at 10,000 feet, according to the BOM map.

The Horsham METAR would be for a very localized area, so couldn't be relied on for a more general picture of the weather in the area.

R.I.P. Don. It was a long time ago now, but still have fond memories of the good old days at YBRS.

After reading the report, I wondered: Is there higher country on a direct track between the Kenmore Gap and Nhill? (Not familiar with the area).


It looks to me like he was navigating from town lights to town lights, and missed a set of town lights. This may have contributed to him mistaking Wallup for Nhill, and he seemed to be wandering around looking for Nhill airstrip in the wrong area.






Add in last light, "must get home itis" from passenger, nervous passenger, unwell passenger, long day...sadly, a terrible ending.
I agree with previous comments that the report could be a lot more (factually) informative than it is, by including weather reports and other such pertinent information. Can anyone tell me why some information is included in the prelim report, but dropped from the final?

Up until about Wallop there would unquestionably have been daylight. I don't believe he was navigating from town lights to town lights. (Also note that a number of the points mapped by the ATSB are not towns and do not have significant lights - including Wallup).

The ATSB conveniently don't show this detail, but he flew directly overhead Warracknabeal airstrip. You need to overlay the track on google earth to figure this out, mapping the aircraft route by reference to roads and paddock shapes.

From the take-off at Bendigo it looks pretty clearly like he tracked for Warracknabeal with some excursions off track for terrain or weather or both. Once he got to what the ATSB have labelled " Boolite" he changed course and flew a much straighter course which is the direct track to Nhill. My guess would be that he got Warracknabeal in sight and selected " Direct To" on the GPS and was tracking direct to Nhill. The point at which is changed direction direct to Nhill is about where the terrain becomes as flat as a pancake. The flight could have been completed at 200 ft AGL (or possibly lower) from this point.

The $64,000 question - which the ATSB do not really address - is why after nearly 10 minutes of straight, steady cruise (after the Boolite turn) did the changes of direction and wild speed excursions (+/- 20 kts) start? If he changed his mind about proceeding, you'd expect he'd fly 5 minutes in the opposite direction and land at the airport at Warracknabeal which he had just overflown. Note: Warracknabeal is a large 2 runway airport with a PAL equipped 1370m sealed runway. It would have been hard to miss.

If one was uncertain of position, the natural thing would be to fly to the lights of Dimboola (7 nm South), which I would expect would have been quite visible.

But given that he had (I believe) a yoke mounted iPad, I think he knew exactly where he was. I don't think the ATSB has correctly identified the cause of the accident.

Why?

Disorientation due to the dark night conditions and it's why the ATSB are focusing on "dark" night conditions at present, aka ABC Marree Squirrel. Whether that be dark because of cloud cover, a lack of ground lighting reference or rain, it's the same result, a dark night. Like I said a while back in this thread, throw a blanket over the windscreen of the majority of NVFR rated pilots and see what happens.

XXX

I still disagree. The ABC accident was very, very different. I've flown in both areas at night and outback SA at night is a completely different experience. And the ABC chopper was just taking off and not established in cruise, whereas the Cherokee was in stable level flight and had been for some time. I don't think the 2 accidents can be linked.

This Cherokee was about 8 min after sunset, 12 min before last light with a clear horizon (below a BOM estimated 2,000 ft cloud base). He was flying west directly into the sun and would have seen every last ray.

The ATSB report says there were ground witnesses who could see the aircraft. My experience is that people on the ground cease to be able to see aircraft before the pilot ceases to see the ground. This supports my suspicion that it wasn't fully dark. And there would have been reasonable ground light and reflected light from clouds emanating from up to 9 towns within visible range.

As much as we are not ATSB investigators and if we were sitting at the aero club bar, what would you say might have happened?

XXX

The first thing is that I think its worth noting that there has probably been more incisive debate on this thread than is evident in the ATSB report. The windmill I'm tilting at is that these reports are not transparent, do not present primary data, do not critically evaluate alternate hypothesis, and frequently present facts differently than the preliminary report.

The afternoon of the accident I flew into Tullamarine from Adelaide. I'd chosen a burner instead of my aircraft, so I was interested in how the weather actually turned out. I recall that it was better than I expected behind the front. While it may have been a putrid day, I'm not sure it was so bad at the time.

Despite the ATSB having METAR's , BOM observations, and eye witnesses, its evidence of the actual weather is scant. There is lots of rhetoric about how bad the weather had been, but very little on how it actually was at the time.

I started to become interested in this case after it came out that the pilot stopped at Bendigo and rang for weather. I reckon the decision to land is harder than the decision to stay once you've landed. So I was interested in what the pilot learned that would encourage him to keep going. I'm disappointed that the ATSB report gives no insight into this whatsover. But whatever happened was enough to coax nervous passengers back into the aircraft. I think we deserved a critical review of the veracity of the weather information.

If I were flying I'd get to Warracknabeal and think the hardest part is over and you could easily " straight line " the final leg to Nhill at 500 ft. You'd see Dimboola & Horsham on the left, then the runway lights at Nhill where you could do a straight in approach and get on the ground quickly.

If there was an autopilot on board (which the ATSB doesn't list) it would be a matter of engaging it and flying on for only about 10 - 15 min.

If you didn't like it a U-turn and a flight not much longer than you could hold your breath would get you back to Warracknabeal.

I know some guys at Yarrawonga (the pilots base) and have head some stories about the pilot. I was ready to blame the pilot, but now I just don't think its that easy. I'm not sure that the flight path fits with a pilot gradually losing spatial awareness either.

I think something else has happened. I suggest 3 hypotheses
1. the ATSB has made no attempt to explain the unfastened passenger seatbelt. They do acknowledge that the passengers were very anxious. To my mind, anxious passengers tighten seat belts, not remove them. I wonder if the passenger had a panic attack and distracted or disturbed the pilot.
2. I hear from Yarrawonga (and significantly omitted by the ATSB report) that the pilot had a yoke mount for his iPad installed the day before. I wonder if its batteries went flat and the pilot had become too dependent on it and became disoriented in his attempt to transition to another navigation reference. It would be nice to know from the ATSB if the iPad still had charge and what other navigation instruments it had (ie did it have an ADF which was tuned to Nhill??)
3. If this was the first time he used the iPad at night, was there something about its operation that was problematic - eg, was it too bright to see the AH clearly? Was the AH visible at all over the iPad??

I think there was a real opportunity to learn from this. Instead the ATSB has opted for the easy VFR pilot into instrument type conditions - blame it on the dead pilot pigeon hole.

The ATSB's conclusion and (1), (2) and (3) above, all result in the pilot losing control of the aeroplane - with the same outcome!

Dr :8

Well said, Old Akro.

If correct i think thats a major detail.

My first question about the ipad would be just how were it mounted? Did it obscure part of the panel?
The pilot, though night rated, planned for and set off on a day VFR flight - six pack not needed. Perhaps the ipad were mounted for an expected VFR flight in a convenient place to 'play' with the new nav device.

Possibility - Having an eight inch wide cockpit dominating bright screen presenting an illusory sort of artificial horizon jiggling just below the A/H would be very disorientating.

It is likely the ATSB have looked at far more then presented in the report. The dificulty i guess is writing a report that covers the main points the investigators believe to be the cause though is of sufficient brevity that pilots will actually read and learn from it. That said, it would be interesting to know more about the aircraft panel layout and more about that ipad?










.

There is a dimming option at the top right of the screen (depending on the software he was using) that would bring it down to next to nothing brightness. I wouldn't go pointing at iPads just yet. If it is related to his iPad there's a very easy lesson for all of us in there to get familiar with any new equipment prior to flight, particularly a more "difficult" flight such as this one with additional hazards. Who knows, he may have been using an Ipad for ages and only coincidentally happened to have it yoke mounted more recently.

XXX

Agree - except that 2 years & 4 months ago iPads were not as common as now and I think OzRunways was still new and I don't think AvPlan existed. I think this was the old iPad 1 era???

But - why hasn't the ATSB addressed this in the report?

There are a few other details that might be germane too:

1. Did the aircraft have an autopilot?
2. If so was it coupled to a Nav source, or driven by the heading bug? Or was it a wing leveller? Was it operational & engaged?
3. Did it have a VOR? Was it tuned to Nhill?
4. Did it have an ADF? Was it tuned to Nhill, or Horsham or Warracknabeal? Were all these ground aids serviceable at the time?
5. Did the NVMC flight review (conducted a month earlier) cover navigation by these aids?
6. The ATSB said it had a panel mount GPS. Was this operational & programmed? Did it have an up-to-date database?
7. Nhill & Horsham have dial-in AWIS. Had either of these been accessed by the pilot?
8. Nhill, Horsham & Warracknabeal all have PAL. Had any of these been activated? The accident was less than 30nm from Nhill which is around the point I'd be activating PAL. Activation of Warracknabeal or Horsham may indicate a change of plan.
9. What altitude was he cruising at? (altitude excursions are graphed, but not altitude)
10. At last light, exactly which town lights are visible from this cruising altitude?
11. Did the ipad still have charge? If he hadn't charged it during the day, its battery life was probably struggling. Could the iPad running out of batteries be an issue?
12. Did the iPad have an external GPS unit? I've had some bizarre readings from iPads a bit North from this area when they lose the aid of Next G signal (without an external GPS engine) - especially with the early generations of OZRunways & iPad generation 1 - I sent OzRunways a number of screen shots of OZRunways showing the aircraft tracking 90 degrees from its actual course about 50nm North from the crash location.
13. Was the iPad mount a propriety one? Or a home made jerry-rig thing? Was it fitted and / or signed off by a LAME? Did it obstruct view of the instrument panel?

This might be the first accident where an iPad was relied upon for navigation (if not used for primary navigation). Nearly 2 1/2 years ago the EFB rules were significantly different. You'd think a review of EFB use might have been relevant.

A question I would have liked considered is: Is it possible this flight would have had a better outcome if he had used flight following? Basically, I only fly 8/8 blue VFR or IFR, so I've never used it. But I hear a lot of guys being denied it on the radio. But should we be encouraging the use of flight following in difficult VFR days like this? Would it have made a difference?

I've had experiences in Western Victoria where the actual weather was nothing like the forecast. I was hoping for an analysis of the forecast the pilot received vs actual. The guy landed at Bendigo because he didn't like the weather. What changed his mind? Frankly, I think a thorough report would have appendixed the actual report. And why was the Horsham METAR included in the preliminary report deleted from the final report?

The benefit of asking these questions is that it might provide flight preparation lessons rather than simply blaming the pilots night proficiency (despite it being greater than required by CASA regulations).

The only lessons from this report are to ring the elaborative briefing number rather than rely on the NAIPS briefing and to fly more and be more proficient. I don't think there enough analysis in this report which would cause a NVFR pilot to do anything differently. I don't think its achieved its objective.

Anyway, its time to move on. It was a very sad accident. The pilot clearly made some errors in judgment, but also his actions at Essendon and Bendigo also suggest he did some good things to try and get good information.

My main issue with this thread is that after 2 years and 4 months, I think the ATSB have done a very poor job of investigating it.