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VH-YTM final report
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So sad and so unesesary -:( |
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I haven’t yet found the flaw in ATSB reasoning, but I used to do something like this sort of work years ago. While I may well be mistaken, ATSB has come to some what appear to be startling conclusions; 1. Angel Flights are seven times more dangerous than ordinary private operations. These private operations themselves are more than twenty times more dangerous than charter and RPT. This implies that Angel Flight pilots are seven times stupider than the general GA pilot population or, as ATSB seems to suggest, there is a reality distortion field around ATSB operations that makes people idiots (seven times stupider!) when operating an Angel Flight. But wait! There’s more.... Table B5, Technical occurrences, shows that the aircraft knows it is on an Angel Flight compared to a private flight and being malevolent, responds by making things break or fail in flight. The possible exception may be the engine, which seems to be non sentient and fails without regard to who is driving or where they are going. Then of course there is the weather, birds and wildlife, all of whom seem to have it in for angel flights. I have to say I am not convinced because “category of operation” is a rather imprecise term. We are not comparing apples with apples I think. For example a private operator doing dozens of scenic s from his home airport is not exposed to unfamiliar airports and less than perfectly sunny weather. A fairer test would be to look at private flights that match Angel flight trip durations - say four hours there and back and compare those safety occurrence records rather than comparing angel flight with someone doing circuit training. Anyway, that’s my opinion FWIW. |
If you really think that this isn't a case of an inexperienced operator uselessly plunging off into IMC (after just somehow miraculously not killing themselves in it minutes earlier) due to a perceived pressure that they were unable to accurately and effectively rationalise and mitigate, then you're kidding yourself.
I think that's the only really important part of the report. The stats and the like, I agree, seem pretty heavy handed and I'm not entirely sure what accuracy or even relevance I'd give them. At the end of the day the actions of the PIC were inexcusable. There is no safety related “fix.” What was carried out was a violation. In the future, there needs to be an assessment of what motivated the violation, and how to mitigate that risk in the future. If the answer to that is instituting tougher requirements, then that’s probably okay in my opinion. The death here was needless, tragic and genuinely avoidable. That CCTV imagery is just genuinely horrifying. I can't fathom how anyone could rationalise launching BACK into that, with passengers, after so narrowly avoiding disaster and cheating death the first time; and yet it happened. Why? |
Junior LFA you are right. I have no problem with that. Similarly the previous accident I think. But how do you extrapolate from two fatal accidents in ten years of operation to “systematically unsafe”? That is where I may have issues. I can’t help thinking that there is some well connected greaseball waiting to launch a taxpayer funded alternative to AF. As for the statistics about RPT being dramatically safer, it probably is, but one A380 going down in Sydney CBD will change that. Accident occurrences in RPT are very infrequent but large. The Feyneman appendix to the Challenger report is still worth reading again and again. |
Originally Posted by Sunfish
(Post 10543749)
Junior LFA you are right. I have no problem with that. Similarly the previous accident I think. But how do you extrapolate from two fatal accidents in ten years of operation to “systematically unsafe”? That is where I may have issues. I can’t help thinking that there is some well connected greaseball waiting to launch a taxpayer funded alternative to AF. As for the statistics about RPT being dramatically safer, it probably is, but one A380 going down in Sydney CBD will change that. Accident occurrences in RPT are very infrequent but large. The Feyneman appendix to the Challenger report is still worth reading again and again. |
The answer to AF’S problems might be what my Dad did for me and I did for my son and others have done for their kids......An insurance policy; “if you have had too much to drink, or don’t trust your driver, then call a cab, anywhere, anytime, we will pay the cab fare absolutely no questions asked.” I only ever availed myself of that maybe twice, my son with me likewise. How difficult would it be for AF to have an IFR professional and suitable aircraft as a backup on call, so a volunteer can bail without letting their patients down if they feel things are getting beyond them? Having someone on call would cost money, but there would still be lower costs than a full professional outfit. |
It’s beyond sad when the ATSB so shamelessly manipulates statistically insignificant data and coincidental clusters to support CASA’s knee jerk response to accidents during private ‘community service’ flights. Imagine living with the worry that something at your workplace could be causing cancer. That's the reality for workplaces caught in a cancer cluster scare. The latest alarm has been raised at the ABC's Melbourne studios, three years after a cluster of 17 breast cancer cases at the ABC Brisbane headquarters forced the site's closure. Cancer experts say that in 99.9 per cent of clusters investigated, there is no underlying cause found, meaning that most clusters are mere coincidence. But that's little solace to staff members comforting stricken colleagues and wondering if something in their work environment might be threatening their lives. If CASA and ATSB were left to deal with this kind of stuff, mere coincidence and scaremongering statistics would be the basis of most regulatory activity. Oh wait... So I’ll have a go at summarising the safety messages from the YTM tragedy: 1. Don’t fly in IMC if you don’t have a current IFR rating. 2. Resist external pressures to fly when you shouldn’t. 3. As a consequence of 1 and 2, always have a Plan B and a Plan C. If only these lessons had been learnt before and some organisation were funded and responsible for aviation safety promotion - constantly and effectively repeating these messages and getting them across. Oh wait... |
Originally Posted by Sunfish
(Post 10543754)
The answer to AF’S problems might be what my Dad did for me and I did for my son and others have done for their kids......An insurance policy; “if you have had too much to drink, or don’t trust your driver, then call a cab, anywhere, anytime, we will pay the cab fare absolutely no questions asked.” I only ever availed myself of that maybe twice, my son with me likewise. How difficult would it be for AF to have an IFR professional and suitable aircraft as a backup on call, so a volunteer can bail if they feel things are getting beyond them? |
The memorial to the victims should be a better service, not no service. |
Looking at the CCTV images in the report, the pure contempt this individual has for the lives of his passengers and himself is inexcusable. Whatever flight school turned out this product just 2 years before the accident should be very proud:D |
Flight schools can't be held accountable for the decision making of a private pilot 3 years later.
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Correct: We should blame Angel Flight. |
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r https://www.atsb.gov.au/media/577660...-069_final.pdf
https://www.atsb.gov.au/media/27144/aair198902571.pdf The first link relates to the ATSB report just released on the crash of the Tobago at Mount Gambier in June 2017. The report took just under two years to produce and contained approximately 90 pages. The vast majority of the report had little to do with actual loss of control. No wonder it took two years of delay before the report was released. Some readers may consider much of the report was superfluous. Unless interested in the legal minefield exposed in the report, most ordinary pilots would prefer to bypass the heavy stuff in order to get to the guts of the accident and hopefully learn from it. The second link relates to the ATSB report on the fatal crash of a Grumman Cougar in August 1989 where an engine failed shortly after takeoff at night and the pilot lost control. That report took 12 months to be released and covered just four pages.. In contrast, the difference between the length of the two reports is notable. In both cases the cause of the accidents was loss of control less than a minute after takeoff. |
Re the CCTV/Cam images; I have noticed with our own web cam that if there is some moisture on it then the image looks worse that what it does if you go outside and look with your eyes. All I'm saying is that there can be a difference and that difference may be behind a decision that ended up being wrong.
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Safety Digests have been telling us for yonks that experience is the key.
But CAsA doesnt believe that, just being a PPL, whatever yr experience, CAsA believes yr are bloody dangerous and do all the killing, And now.! ..if you go Angel Flight this/ any PPL is 7 x more bloody dangerous..! Interesting "theory" CAsA's reaction comes about because CAsA hate not being in Total Control and all times. Once Pilot gets in the cockpit and starts up, a decision is made and there's absolutely nothing CAsA can do about it. The pilot is exercising the PPL licence with incredibly stupid decision making In both cases , both decisions to continue, were flawed and (tragically) fatal. Its the decision making that is at fault. How to instil that into people.? Is there specific 'decision making' lectures for PPLs these days? Maybe you just have to be a natural coward ( thinks, I could kill myself doing that !) and be 'risk averse' under certain circumstances...like entering IMC unqualified and pushing on in the coming dark, no NVFR. Many years ago there was a run of CHT accidents in the Straits and Cape York, 7 of and 21 fatalities in less than a year. Did CasA make any changes to the way CHT is conducted in remote areas...and vilify CPLs. No. That's just the way it is. What was the title of the article regarding the fuel runout crash in Columbia, Bolivia?.. "Pilots, We can be heroes or murderers" Sums it up nicely |
Would it be safer if Angel Flight pilots held instrument ratings?
In the USA over 80% of private pilots hold instrument ratings when practically none do here. Why? In the USA it is affordable because it is not bound up in bureaucratic bullsh#t that doubles the cost of gaining one. A classic illustration of how over regulation diminishes safety by suppressing participation. Air travel is the safest mode of mass transportation; your odds of dying in a plane crash are about one in 11,000,000. That's an average of about 110 people per year, and those numbers include private planes and non-crash related accidents in addition to commercial travel. In fact, you're more likely to be struck by lightning, with a one in 13,000 chance for your lifetime. That's why the ATSB report is so flawed. They doctor their statistics to suit CAsA's agenda. If CAsA had the courage of their convictions they would just ban community service flights. Children dying of cancer or on the road to see their specialist would be on their heads, not that they would give a sh$t. |
Those conditions don’t even look suitable for IFR flight. Agreed on the webcam though. Air services give us a low quality low res image and keep the good ones for themselves. It would have been good to see the proper images. |
Senator Rex Patrick's response to ATSB report.
"Angel Flight offers an invaluable service to families in regional and remote areas burdened with an ill or disabled family member. Only two nights ago I spoke with Senator Hollie Hughes’ who had used Angel Flight for her own autistic son, Fred, to access city services from remote areas of NSW. She described it as a Godsend. The findings in respect of community service flights are intensely bureaucratic in nature and clearly written by people sitting at a desk in Canberra without reference to any of the thousands of families that have been helped by organisations such as Angel Flight. Indeed, it's hard to take the report’s analysis of Angel Flight seriously. It asserts that many flights can be replaced by commercial services almost blind to the costs of regional flights, their limited routes, and their limited schedules. Indeed, the data the ATSB uses to support its claim are based on the very narrowest of data sets. The ATSB uses ‘lies, damned lies, and statistics’, coupled with predominantly subjective analysis, to portray community service flights as unsafe. Angel Flights use experienced pilots and safe aircraft. There is no difference in the safety case associated with a CASA certified pilot flying a mate to the footy in Melbourne and a CASA certified pilot flying someone to chemo therapy in Melbourne, except the ill patient is more aware of the qualifications of the pilots and the risks associated with a flight. Its Pel-Air (Norfolk Island ditching) all over again - for that particular report the ATSB were found to be grossly incompetent and were ultimately required to redo the report. If CASA and the ATSB were in charge of road transport, no one would be allowed to use the roads." |
Wow! Great to read Senator Patrick's comments but the arrogance of CASA and ATSB will mean it will largely fall on deaf ears.
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But wait, there’s more....... In using the safety system “occurrence” database for what is clearly a partisan political purpose - helping CASA destroy Angel Flight, the ATSB has not only utterly compromised its alleged independence but has destroyed any faith in the alleged anonymity of ALL reporting schemes, both mandatory and voluntary. As for the analysis, I fail to understand why the ATSB has not discussed or commented on its startling finding that Angel Flight operations are seven times more dangerous than ordinary GA operations. The only reason I can think why is that at least someone is ashamed of this hatchet job. It appears ATSB is now part of the problem, along with CASA. To put that another way, I am aware, I think, of safety occurrence reports that are, to put it mildly, less than frank about what happened. The current ATSB behaviour seems to provide a strong disincentive to report anything at all if it can be avoided. |
Angel Flight offers an invaluable service to families in regional and remote areas burdened with an ill or disabled family member. Only two nights ago I spoke with Senator Hollie Hughes’ who had used Angel Flight for her own autistic son, Fred, to access city services from remote areas of NSW. She described it as a Godsend. The findings in respect of community service flights are intensely bureaucratic in nature and clearly written by people sitting at a desk in Canberra without reference to any of the thousands of families that have been helped by organisations such as Angel Flight. Indeed, it's hard to take the report’s analysis of Angel Flight seriously. It asserts that many flights can be replaced by commercial services almost blind to the costs of regional flights, their limited routes, and their limited schedules. Indeed, the data the ATSB uses to support its claim are based on the very narrowest of data sets. The ATSB uses ‘lies, damned lies, and statistics’, coupled with predominantly subjective analysis, to portray community service flights as unsafe. Angel Flights use experienced pilots and safe aircraft. There is no difference in the safety case associated with a CASA certified pilot flying a mate to the footy in Melbourne and a CASA certified pilot flying someone to chemo therapy in Melbourne, except the ill patient is more aware of the qualifications of the pilots and the risks associated with a flight. Its Pel-Air (Norfolk Island ditching) all over again - for that particular report the ATSB were found to be grossly incompetent and were ultimately required to redo the report. If CASA and the ATSB were in charge of road transport, no one would be allowed to use the roads. Here is the crux of the problem: “invaluable service”. CASA does not put a value on community service flights and, even if it wanted to, it wouldn’t know how to balance that value against the cost of the risks. And once you resort to the rhetorical question: “what price a life?”, any mitigation at all is justifiable. |
Originally Posted by thorn bird
(Post 10544442)
Would it be safer if Angel Flight pilots held instrument ratings?
In the USA over 80% of private pilots hold instrument ratings when practically none do here. Why? In the USA it is affordable because it is not bound up in bureaucratic bullsh#t that doubles the cost of gaining one. A classic illustration of how over regulation diminishes safety by suppressing participation. |
Ho Hum, ops normal ...from the bureaurats any old bull**** will do.!
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Originally Posted by Lead Balloon
(Post 10545540)
Hear! Hear! Senator Patrick. Here is the crux of the problem: “invaluable service”. CASA does not put a value on community service flights and, even if it wanted to, it wouldn’t know how to balance that value against the cost of the risks. And once you resort to the rhetorical question: “what price a life?”, any mitigation at all is justifiable. ‘’But that matter is dealt with every day by actuaries and risk management professionals. The ICAO understands it. https://www.icao.int/safety/SafetyMa...alltext.en.pdf |
Of course: it’s unavoidable in the real world where there is no such thing as zero risk. One description for it is “affordable safety”. |
Full page advertisement in today's The Australian paper from Angel Flight.
https://cimg3.ibsrv.net/gimg/pprune....e9e84579a6.jpg |
Good to see Angel Flight defending themselves. That report is a joke. If that was a school assignment it would have been handed back with a big “F” stamped on it and an instruction to resubmit. Come on ATSB, that’s just embarrassing. What the hell is going on..? You’re trashing the legacy of what was once a world leading investigation agency. I just don’t understand how they can sign off on this tripe and think it’s acceptable or that no one will question its veracity. |
Originally Posted by IFEZ
(Post 10546569)
I just don’t understand how they can sign off on this tripe and think it’s acceptable or that no one will question its veracity. |
I agree with the general sentiment here that the ATSB report has a strange focus on irrelevant, plucked "statistics" that serve to make Angel Flight look bad.
However, from the first paragraph under the "Recommendations" heading in the Angel Flight response in the Australian is this: The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather. It is regrettable, that the Bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions Should the ATSB have said - "Pilots are reminded that they should remain VMC when they or their aircraft are NOT rated for flight in IMC - IMC is commonly recognised by NOT being able to see the ground and sky outside at the same time..." FFS, I agree with most of what they have said in the article, but they do themselves no service by making silly statements like those... Had Angel Flight offered any "safety recommendations to pilots flying light aircraft in bad weather."?? I think it's more their responsibility than the ATSB's... |
Based on what's been presented, there could surely be no safety recommendations beyond what CASA, ATSB, and every school and instructor ever says...DO NOT FLY INTO IMC IF YOU OR YOUR AIRCRAFT ARE NOT SUITABILITY EQUIPPED OR RATED.
You can be caught out whilst airborne and the PIC may be able to offer some kind of reasonable explanation, but to make the decision to launch into it from the ground really is inexcusable. |
It’s really no different to one of their ground based earth angels, speeding to the hospital in a vehicle type that they are not licensed to drive. |
Joseph featherweight and BigPapi you are both on the money. ATSB ridiculous sector comparisons are not feasible or reasonable. The obvious conclusions from this and the other AF fatal incidents are that the pilots f****d up and in my mind were driven by getthereitis which is the critical factor that must be addressed by AF in controlling how well intentioned pilots carry out there missions. Over the top actions by CASA will not solve this problem - more safety education might do so. |
Irrespective of what ATSB continues to do to ensure its trashed reputation remains trashed, there should be: 1. More effective safety education, including more effective human factors education, not mere words parroting lessons already learned and not mere seminars and videos the equivalent of “drugs are bad”. They don’t count as “comprehensive safety education and training programs” in terms of CASA’s functions. 2. Less complicated (and therefore less expensive) paths to highly experienced private pilots to become instructors of key airmanship issues. Private VFR pilots with thousands of hours in their logbooks have a better insight into the practicalities and risks of VFR flight and human factors risks and, more importantly, more experience in how to mitigate them in the real world, than a freshly minted CPL Grade 3 instructor or an ATPL with 20,000 hours at 35,000’. Any idiot can say: “just don’t fly VFR when the weather’s IMC”. That’s not how to effectively mitigate the risks of ‘getthereitis’. 3. Less complicated (and therefore less expensive) paths to IFR ratings. PIFR has been stuffed by the complicators. (Yes I know that some theorise that the conditions at Mount Gambier in this case were not conducive even to IFR flight. That merely reinforces the other points.) |
We have, to date 6 deaths resulting from poor pilot decision making. The 2 AF pilots where licensed & qualified for the tasks at hand under the rules & regs governing each flight. We can all pontificate here 'till the cows come home but the basic facts are that both pilots made intentional decisions that had tragic outcomes, WHY? That question will always remain unanswered despite all the education/reports possible!
Humans are not very good at following rules, we see this demonstrated daily, we are a complex being & influenced by many factors for decision making even at times despite the obvious! Can't bring those people back but can we learn from their demise? Sadly no:-( |
Just don't fly VFR when the weather's IMC.
I must be an idiot. Edit: -in credit to you Lead Balloon I very much understand what you're saying, that's not effective education or risk mitigation/management. But in this case, this wasn't a pilot that got caught out airborne, or made a marginal judgement call about cloudbase or visibility in a shower, this was a pilot who made a conscious decision to take off into IMC conditions. |
The problem with this ATSB report is that it has been used to pursue a political agenda against community service flights. The accident itself was tragic and the cause pretty much black & white without any real extenuating circumstances. They pilot had trouble landing visually. What bigger sign do you need to not immediately turn around and take off?? All pilots like me who have cancelled Angel Flights due to weather know that the Angel Flight organisation is extremely understanding and supportive in such circumstances. The ATSB maliciously misrepresents the Angel Flight accident rate. It does not count the full hours of Angel flights. And the life’s of the poor passengers are no more (or less) special because its an Angel Flight. This accident should be examined as an accident regardless of who is on board. The CASA argue meant that community service flights should be charter flights is completely flawed. A private pilot should be safe to carry passengers. Period. The CPL training and study is about working in a commercial environment that runs to time, has last minute changes, carries minimum fuel and is done day in day out so that duty times are an issue. The ATSB / CASA should be really use these accidents as cause for reflection on a) whether the PPL flight training requires improvement, b) if the CASA safety education mechanisms are working and c) whether CASA’s bureaucracy around IFR ratings is discouraging pilots from becoming IFR rated and how many lives would be saved if Australia had the same level of IFR ratings as the US. There is a real argument that CASA’s over regulation of IFR is costing lives. |
I'm glad my underlying point was not lost, BigPapi. One of my many faults is that I tend to be too blunt/sarcastic. My apologies for that.
Just as any idiot can say: "just don't fly VFR when the weather's IMC", any idiot can pass another law or impose more restrictions each time someone dies in an aircraft accident. That was the point of Senator Patrick's analogy. |
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