"a fiery plane crash" eh, Georgia Clark?
I'm pretty sure there wasn't a fire.
(But this was from the Daily Telegraph.)

Those aspects were quite well covered in the report. However, accidents rarely have one cause and it's worth looking into other contributing factors.

The pilot wanted to stay at 6500, and the simple way to remain OCTA was to divert about 5 miles right of track. After the initial clearance was denied, the pilot did turn right, presumably that was their intention.

Then the Class D controller provides a clearance into class D (2 way communication constitutes a clearance) with the instruction "at or below 1000 feet" but no tracking instructions. The pilot reads back "At or below 1000 feet", turns back on track and begins descending. There was no reason the pilot would descend other than to comply with the "at or below" instruction.

If there was a communication misunderstanding between the pilot and ATC that resulted in the aircraft descending into the ground in bad weather, is that aspect worth investigating? Or do we just put it down to the fact that he didn't do a BFR?

Nothing to do with paying, everything to do with being VFR.

You all know where this ends up, don't you?

Read the report andrew! The pilot was not given a clearance to descend to 1000', he was advised that if he wanted to transit the CTZ VFR he would have to descend to 1000'

I'm not sure where you get this from:. A clearance to descend would have been prefixed by "You are cleared to...." He was OCTA he didn't need a clearance but if he wanted to transit the Coffs control zone he would only get one at not above 1000'.

The lack of a BFR was an indication of the pilots attitude to his responsibilities as was the lack of planning and obtaining a weather forecast. When will the GA population of Australia stop thinking that if only ATC were better then VFR into IFR accidents wouldn't happen?

Lookleft: When will the BFR be more than an expensive box ticking exercise (unfair to some)? When will the regulations actually encourage safe behaviours? When will enforcement encourage safe behaviour? When will accident analysis and reporting encourage safe behaviour? However that is actually irrelevant.

To put that another way, suppose the pilot was an ab initio student high on drugs and alcohol in a stolen aircraft. Does that absolve Airservices? Of course not! They have no way of knowing the state of the pilot unless she tells them!

The idea that a BFR and a map may have saved them from Airservices is a fantasy.

Thanks Sunfish you have made my point for me. To paraphrase Clinton "Its your attitude stoopid."

Nailed it Squawk! Ahh yes the spite or tone in the reply, maybe even a sigh if you’re lucky hahaha. Love that you don’t let them off that easy with an offer of complete flexibility.... must remember that reply next time!

From the final report:
"At altitudes less than 1,000 ft along a track between the aircraft’s position and Coffs Harbour Airport and more significantly, along a continuation of the direct track to Taree, terrain clearance was not possible. However, the pilot did not voice any concerns with the advice provided and the flight descended on the direct track to Taree." (my emphasis)
Quite interesting.

Is the inclusion of the following a deference to this thread?
"Future Coffs Harbour airspace reclassification
Prior to the accident, Airservices commenced the Airspace Modernisation Program. This program will reclassify the Class C airspace above Coffs Harbour to Class E. At the time of writing, the timeframe for the completion of this program was not available.
Undertaking a VFR transit of the Class E airspace will not require a clearance."

Lookleft- 'I'm not sure where you get this from'

AIP 2.2.12.2 'For entry into Class D airspace establishment of two way communications between an aircraft & ATC constitutes a clearance for the pilot to enter the Class D airspace'

Thanks OH for the reference. It certainly doesn't constitute a clearance to anything else such as climb or descend. For that you need a very specific clearance.

Imported directly from Yanksville, Of course it doesn't need to make sense, as long as they do it it must be OK.

2.2.12.2 needs to be read in conjunction with the table in 2.2.12.3.

If you state your intentions and ATC *acknowledge* your call and give nothing else, you must comply with your stated intentions (ie although they haven't said 'you are cleared', you have been cleared to enter D and your 'clearance' is effectively 'do what you said you would do'). Also you *can* descend to join the circuit if no altitude instructions subsequently given.

If ATC give you specific instructions (which seems to be the more common case), you are cleared to enter D and your clearance is to do what you were instructed (although you *can* descend if no altitude instructions given by ATC).

Also VFR aircraft operating in D are responsible for maintaining themselves in VMC.

What the controller expected and what the pilot understood seem to have been different. I am suggesting that this should have been explored more in the report.

A full transcript of the communications would be useful. The communications that are included are short excerpts out of context so it is hard to be sure what was meant. Listing the events in sequence with timestamps would be useful.

The airspace steps that the pilot wanted to transit were Class D below Class C. He was told to request clearance from the Class D controller.

It appears he had 2 way communication and wasn't told to stay OCTA, so technically had clearance to enter Class D (but the controller may not have expected that).

He didn't receive tracking instructions from ATC, so he was REQUIRED to track according to his request. The controller said clearance was available at or below 1000 feet. The pilot read back "at or below 1000 feet" i.e. he appeared to interpret that as an instruction, and began to descend. He didn't want to descend, which supports the idea that he viewed it as an instruction.

Misunderstandings between pilots and ATC are one of the more useful areas to investigate, because there are often things that can be changed.

As another has stated, the ATC/Pilot comms quoted are out of context and not in their entirety, it is difficult to get a handle on the exact sequence of events. The ATC work does appear to be sloppy though and Airservices response is an attempt to pull the wool over your eyes. Class D Towers in Australia are not operated as to how ICAO intended and if they were modelled on the way the US runs them? Well, yet more wool pulling.

Having said that, any attempt at apportioning blame to ATC for this accident is spurious and deflection at its best. It may be how the legal system works in Australia? Or how accident investigation works?

Intentional flight into IMC by an unqualified pilot, blatant and intentional rule breaches by the PIC, the ones that can (and did) kill people. Clearly no understanding of LSALT, the list goes on.

He would have had to have been in contact with the Class D controller i.e. Coffs Tower for that statement to be correct. Had he descended to 1000' coastal and contacted the Tower for a clearance to transit the Class D control zone it is highly likely that would have been given. don't forget that the controller he was in contact with was a trainee.

I think that is absolutely what happened but we will never know what the pilot understood. I'm not sure that having the full transcript would clarify it either as it can't inform the reader as to nuance and tone of the communication.

As a PIC you are responsible for clearing up any misunderstanding that you may have with an ATC instruction especially if you think it is going to lead to a dangerous situation. It is beyond comprehension as to why the pilot thought that ATC were telling him to descend to 1000' over high terrain. All he had to do was ask for clarification of the instruction. The report stated

Possibly he did have doubts which is why he climbed back up to 4,500'. That was the time to speak up but he then started a descent. I stated in a previous post that ATC will kill you but only if you let them. Despite what some of them think they are not in the cockpit and do not have the authority to make you do anything that you consider will affect the safety of your aircraft and passengers. The main reason these reports are published is to hopefully educate other pilots on how to avoid a similar situation. I would be interested in peoples response as to how this accident might change the way they operate. I would hope that the big lesson learnt is to always be in control of your situation when operating as a PIC.

That’s why the actual recordings of comms, and not selective, mistake-ridden transcripts or summaries of them, should be made available as part of these reports. I agree with the points being made by andrewr.

Controllers in Class D airspace do not have responsibility for terrain clearance. Regardless of what clearance you receive in class D, it’s your responsibility as the driver to keep yourself alive.

A pilot without a valid license, BFR, seemingly unprepared and out of their depth allowed themselves to descend into terrain.

Would a clearance have prevented this? Yes, of course. Should not getting a clearance have been a reason to descend into terrain as a VFR aircraft? No. There was a multitude of other options available to the pilot rather than just accepting a descent to below 1000ft, one must ask if they were even in VMC conditions at all when they commenced that.

If better procedures come as a result of this, then that’s good, and it’s good that the report has spent considerable time detailing the failings in ASA’s processes. It’s not the silver bullet though for what seems to be a continuing list of accidents where VFR pilots allow themselves to hit the ground in IMC. By the letter of the law, the pilot had no business being in an aeroplane that day at all.

Circumstances in which a “controller” is not in control. What possible confusion could arise from that?

And I know, from personal experience, how dangerously incompetent I become the day after my BFR falls due.

Probably minimal confusion if you had read about Class D airspace or done some preparation before expecting to fly into it. If you haven’t been identified, how is a controller supposed to provide you with terrain clearance? Seems like a pretty common sense thing really, wouldn’t you say?

Is the day after the same as 5 years? Just clarifying.

I know it’s always the fault of the pilot. There will never be any other contributing factor in any aviation accident or incident.

It’s actually incredible watching you wheel this out where two posts above I have said verbatim:

“If better procedures come as a result of this, then that’s good, and it’s good that the report has spent considerable time detailing the failings in ASA’s processes.”

😂

But thanks anyway for your informative answers to my above questioning. It’s clear you have no agenda to push.

I seriously doubt I’ve taken away any skill that I didn’t posses before, by doing my last 3 BFR’s or more.

Many pilots take their learning from their original instructors and complement that over the years with idle gossip from the airport about changes to procedures, plus possibly the odd email from CASA about rule changes and possibly if they are lucky, may take something away from their AFR.

The one hour flight time for the AFR and the little quiz that some offer is arguably a waste of time and purely a box-ticking exercise.

Maybe I’ve been doing mine with the wrong operators...

I am confident that for IFR pilots that the story is quite different, however old-mate with his 1,000 hours and his Garmin Aera has probably been flying this way and hasn’t changed since his licence test, like many other pilots out there.

Yep. Spot on. If AFRs achieved anything substantial, there’d be consistency in radio broadcasts.

Junior: My ‘agenda’ is safety.

Maybe all the Chuck Yeagers out there can maintain all the skill they need without needing AFRs, but I'm not ashamed to say that having to get a bit of critical scrutiny from an instructor for a check flight (and then only every two years!) is beneficial for me, and a good reality check to remind me that I can **** up in new and interesting ways even after decades in the seat.

Maybe CASA should be having a chat to any instructor that is merely ticking boxes.

I reckon you probably are.

The Flight Review can also (and should) be a training exercise. An opportunity for the candidate to ask 'WTF goes on in these Class D volumes?' or 'can you run through some radio calls with me' or 'I do a regular flight from Glen Innes to Taree but the track I take is a pain in the arse, your thoughts?' But more often than not you get a phone call saying 'how much will a Flight Review cost me??'

It doesn't matter what class of airspace you are in, as a pilot, it's your responsibility to not hit anything, regardless of any thing a controller says to you or tells you what to do.

How do they handle VFR traffic in class D airspace in Australia?

I mean, in some places they're very much unrestricted, providing a clearance and then traffic information if conflicting traffic should happen making the pilots themselves responsible for the separation (updating if necessary to avoid collision).

ATC in Class D tend to be a bit more bossy, which is fine by me. The last thing I need is to be negotiating with a VFR about the landing sequence in a control zone. :cool:

There are eerie similarities to the old GAAP control zones. I liked GAAP, didn't see the need for change to Class D. However, if you're going to call it Class D shouldn't it be run that way? Another problem with them here is that they all seemed to have developed their own special procedures. Flying in one Class D procedure wise can be significantly different to another. How are you supposed to be consistent as a pilot in the way you operate?

You as a pilot will not be negotiating a landing sequence with another pilot in ANY Australian control zone.

That is the problem. The pilot thought that ATC was in control. ATC are never in control of your aircraft and the way it is operated. If thats the prevailing attitude in GA then good luck you are going to need it. If your attitude towards a BFR is that it is just a box ticking exercise then it is your attitude that is the problem not the rules. I am in the simulator 4 times a year and never do I take the attitude that it is a box ticking exercise and that I have nothing to learn. If you think you have nothing to learn then "its your attitude stoopid" If you think getting a weather forecast is a waste of time then"its your attitude stoopid". If you think that technology has made proper flight planning redundant then "its your attitude stoopid". If you think that safety is all about the system then...you know the rest. Safety starts with your attitude towards flying. Your attitude to obtaining information, your attitude towards using a mandated check flight as a learning opportunity, your attitude towards applying the fundamentals of operating an aircraft i.e planning, weather, fuel. This report states that ATC could have handled the original clearance request differently and Airservices are addressing that through additional training of its controllers. It also very clearly states the PIC was not required to or issued a clearance to descend into the ground. Once he decided that he was required to descend because ATC told him and did not clarify that instruction then the outcome was inevitable. I hope that GA pilots will take some important lessons from this tragedy but from some of what I have seen posted I don't think they will.

Precisely my point. But IFR is theoretically given Traffic on VFR (and vv). So what is it? Do I then have to negotiate with the VFR re tracking, or is ATC just giving me traffic so I can take evasive action if I see fit?

A control zone should be a control zone with all aircraft under air traffic control; none of this "traffic" nonsense. This is, of course, generally the way Australian ATC operate our Class D. Make it Class C and be done with it.

Controlled or Uncontrolled. Sound familiar, Griffo?

Are they never in control of where your aircraft may lawfully be operated?

If yes, best to change the name.

Declare a MAYDAY and you go where you need to go. As a PIC you are always in control of where your aircraft may be lawfully operated. I don't imagine for one minute LB that you ever fly an aircraft where you do what ATC instruct you to do if it conflicts with the operation of your aircraft. I also dont imagine that you have ever rocked up to Controlled Airspace not having an alternate plan if a clearance is not available.

Here's my question to the masses here that doesn't seem to have been actually answered so far, WHY was this Pilot denied a clearance through Class D Airspace in this circumstance? And No, I don't think "Workload" in this case is a valid reason and seems to be some kind of coverall being used.

In Aviation we have many safety nets, everyone knows the swiss cheese model, in this case, the Pilot basically bore themselves a hole halfway through the swiss cheese by not being prepared or legal for this flight, there's NOTHING REASONABLE that can be done about this now without a time machine to go back and force them to take the proper steps, there is also very little I think that can be done in the future to stop someone else making similar decisions. What we can do is look at the layer that does currently still exist and focus on making that better in the future. All the talk about a valid AFR and planning IMHO are moot at this point, they've been put out there and should serve as a warning for all Pilots to not take these things likely but the ones reading it are likely the diligent ones that don't need to be told anyway.

Can we focus on the question of why this clearance for what seems to be a few minutes of transition was denied and thusly this last safety net that could have prevented this and other accidents in the future failed? If we can ignore the other parts we can't really fix and focus on this question then we can get to the heart of trying to find solutions for the future.

I agree with you Lookleft, safety is an attitude. I do all the things you mention religiously and try to apply common sense. It’s a pity that CASA, AsA and ATSB don’t appear to do the same.

‘’To put that another way, who trained that pilot? What was his attitude? Why was that his attitude? What series of errors caused the accident? It’s never one thing like “missing a BFR’ there is always more to it. However the ATSB is unlikely to delve deep enough because I suspect the answer would be unpalatable.

The controller was an early phase trainee so it's hard to label it a systemic issue. "Workload" is a somewhat personal perception - he may have been preoccupied with thinking of other issues he perceived to be more important, got flustered & chose the easy solution of denying a clearance. Was there any indication to the controller that this course of action would be in any way dangerous? I very much doubt it. Trainees in any field often choose less than optimal solutions, provide a less than ideal service & just plain screw up, it's all part of the learning process. The instructor probably saw it as a minor inconvenience for the pilot that wasn't unsafe so didn't intervene - to be discussed later.

Why didn't the pilot simply deviate around the airspace? He'd deviate around weather so why is this any different? Or would that have presented a problem for this pilot as well?

P.S. it was "C" the pilot was denied the clearance for.

As I read it he wasn't denied a clearance through D. The D controller offered a VFR clearance but at 1000' (I assume due cloud - the controller cannot offer a clearance if it would put a VFR aircraft in cloud so offered a clearance that would keep him VMC). I interpreted it as the D controller trying to appropriately accomodate the request by the pilot.

It was the C controller who didn't give the clearance (why he was talking to the D controller). I agree it probably would have ended differently had a clearance in C been given and the denial is a factor and should be addressed.

However the pilot still (IMO) bears a larger responsibility, being denied a clearance should not have been a big deal - a prudent diversion should also have resulted in a safe outcome - or even some polite negotiation ("eg is there an alternative clearance available at a different altitude or track or can I hold until clearance will become available? I need to avoid weather"). The pilot seemed to have had a strong case of push-on-itis which is sadly one very repeated cause of VFR->IMC->accident since aviation began.

As far as no flight review goes - seems more a symptom than a cause. I doubt a recent FR would have changed much for this accident but by avoiding it that raises (to me) a red flag about the pilot's attitude which I do think is a significant factor in the accident.

We all (I assume) agree accidents have multiple causes and establishing them and looking at ways of mitigating them helps improve safety - little can be done to change the pilot's actions in this case however certainly worth asking about any reluctance to give clearances and if this is a problem and if it can be handled better.

Am I right in thinking that a pilot cleared through airspace at a thousand feet would assume that such a flight path at that level was safe? If it wasn’t, what is the point of having ATC if you are not RPT heavy iron?

This dovetails with the class E paper, ADSB, and airspace reform? What responsibility for the mangalore midair? What’s the point if AsA does not take any responsibility the ATSB always blames the pilot and CASA helpfully catalogues all the regulations the pilot broke?

What happens when the non rpt pilot population perhaps one day decides that the regulations are a joke, enforcement is a joke, AsA is a joke and the ATSB is a joke? If we do not have a consistent set of regulations that are grounded in good airmanship, enforced fairly, an ATC system and airspace design that is both efficient, safe and equitable and an ATSB that reports without fear or favor we are asking for trouble.

He had a good second option. He could divert 5 miles right of track and avoid the CTA while remaining at cruising altitude. He had turned right, it appears that is what he was doing.

However, he had requested clearance 4 times bouncing between 2 different controllers. Perhaps when the Class D controller came back with "at or below 1000 feet" he didn't feel like he could say "You know what, I don't need clearance after all." Perhaps he felt obligated to accept what he understood to be a clearance and descend.

Not saying airspace and controllers didn't contribute to the tragic outcome, but put yourselves in the pilot's position - any VFR pilot knows he has to maintain, if not AIP stated vis and distance from cloud conditions to the metre or foot, at least a decent bit of clear airspace out front to continue into and, let's hope, room to turn around if it clags in too much. The investigators found that the aircraft was descending clean in a straight line with cruise power set, not weaving around as you would if you were trying to scud run under low stratus through some hills. I cannot visualise a situation where as a VFR pilot I'd descend into, if not cloud, then at least conditions of such reduced visibility that I couldn't see far enough in front of me to know whether or not there was anything to hit, can you? - and he must have known there was cumulo granite there, surely.