The controllers are copping some flak here because there was no traffic. What about the scenario where there was a conflicting aircraft on descent into Coffs? As others have said, you've got to be ready for the worst.

Precisely what VFR in Class E is all about. Just go and do your own thing, don't concern yourself with anybody else. They will (probably) keep out of your way. :cool:

What was it during his training that made him decide that it would be better to take the easy way out and deny the clearance though? Nothing takes away from the Pilots responsibility in this but I don't believe there is anything that can be changed to Pilots training syllabus or requirements, in general, to address this issue unless we're going to start denying Licences based on perceived "Poor Attitude" either during their training or AFR, even then clearly this person wasn't able to legally fly and chose to, as such no real changes there I think would have affected that part of the flight at all.

This is the problem in these discussions, we're so focused on the minutiae instead of actually discussing the relevant parts that could be fixed for the future. In this case, the Pilot is dead, we can't pick his brains to figure out exactly why he chose to make the decisions that he did and I don't believe any changes to regulations would prevent this from happening. What we do have are the Controllers who were on that day and whose brains we can pick to see why they made their decision and what can be done in the future to enable them to make different decisions and instead all we're getting is "Workload", I don't think this is good enough. This isn't about just one incident either, I'm sure we've all been in situations where clearance was denied with 0 traffic around and no particular reason that we can see, but the thing is there HAS to be a reason why, was there something else happening in the background? Was that controller overloaded with other sectors? Did they just decide not to because they didn't have to and decided that was good enough? I think the fact that a lot of Pilots don't really trust the ATC system in this regard means that the trust is very reduced and more needs to be done to at some level to restore that. Flight Instructors, ASA Instructors, Controllers, Pilots, Ground Handlers, CASA and everyone else involved in Aviation are part of the safety net from start to finish, when there is an incident there isn't always much that can be done and focusing on the things that can't be fixed doesn't help anyone at all.

I assume it would have been safe if he was there, he never got into that airspace, he was in G airspace, he descended into what I am assuming must have been IMC and unaware of what was outside, into the ground well before he got to the airspace.

You are responsible for maintaining VMC in G, in this case, while in G he flew into cloud.

The pilot may have been mentally overloaded or unsure of procedures which is tragic and if there may be systems/procedures we can put into place to reduce the chance of such problems leading to catastrophe, (should a pilot be overloaded and out of their depth), they should be investigated but we are supposed to be trained and operate to a standard where flying VFR, we do not deliberately enter IMC.

Would you fly into cloud to make the requirements for an upcoming clearance? Surely you wouldn't. This pilot did. The failure to get his requested clearance was a factor but similar things happen daily without it leading to catastrophe because pilots take appropriate courses of action to work around it. This pilot didn't. Why? We cannot know for certain, and while I think ATC actions were factors the pilot's choice to proceed into IMC was a major factor.

Saying he must have felt he had to do it to comply with ATC even if it meant descending into cloud seems like a problem more at the pilot's end of the spectrum rather than ATCs, to me. That may include his training or perhaps his age/cognitive state.

Ixixly, how about training pilots to always have a plan B?

Controllers are trained to say "no" as part of ensuring workload remains manageable, it's part of the job because if the workload exceeds your ability to handle you're no longer in control. You don't just say "yes" without considering the consequences - a random unannounced flight presents a challenge because you need to work out where they are & how you'll separate. You don't just make it up as you go along but continually plan.

There will always be situations where a controller will say "no", there is no way of avoiding that. As I mentioned, airspace is just another obstacle to be avoided if a clearance is denied, no different to weather or terrain, so treat it as such.

This is what I had been thinking after reading the report again:

- The pilot was tracking from Murwillumbah to Taree and for the most part, the track was exactly that.
- The fact that he asked for a clearance to enter Class C was merely as he was going to pass through a small chunk of airspace and it would have been convenient.
- He gets bounced around and annoyed with ATC so comes up with another plan.
- He reports as ‘currently 4100 in clear and we’re OCTA' as you would expect with an update as he exited their airspace to do his own thing.
- He climbs back to 4,500ft for 5-6 minutes to remain hemispherically correct.
- Based on the track, he clearly has no intention of entering Class-D at 1,000ft or below as he'd have to turn 45 degrees left, a long way off track and may be over solid cloud at this time. Why would you, as he can't get down?
- He recalls that the cloud base is 2000-3000ft after witnessing it out of Murwillumbah.
("At the time of the incident the region was covered in widespread broken low cloud. With bases generally between 2000 - 3000ft above mean sea level")
- He checks the GPS and looks ahead knowing that past Mount Moombil area, that the terrain is very low and will likely be well clear of cloud.
- A controlled descent begins through cloud. ("The descent rate averaged about 850 ft per minute with a groundspeed between 165 kt and 175 kt") - this does not sound like an out-of-control descent as testified by the previous owner of the aircraft.
- Impact at 2,900ft.
- Had the descent begun only a couple of miles later, he would have missed the mountain completely and been in clear skies at 2000-3000ft.


BUT..... then I looked on the map and realised that he still had 90 nautical miles remaining!
Once I realised that, his actions made no sense, except for if he believed that the cloud ahead was worse than what he was currently experiencing and he needed to be under it.

The rest of his actions aside from the descent all made perfect sense and when you look at the airspace versus his track, then you can hardly blame ATC for such a tiny part of a bigger picture.


https://cimg7.ibsrv.net/gimg/pprune....f125bed14d.png

https://cimg2.ibsrv.net/gimg/pprune....a1dfd76c00.png

https://cimg7.ibsrv.net/gimg/pprune....bc3f37045d.png

He has Class D in the step ahead of him. I suspect the GPS didn't give an easy indication of the exact altitudes of the steps, just that they were there.
I think the Class D in front of him, on track was what he thought he had been told to transit at or below 1000'.

A “clearance to descend” (if that’s how it was interpreted) does not imply that the pilot was allowed to descend below 1000ft in IMC in a VFR aircraft.

There seems to be two mindsets commenting in this thread:

a) those that think the clearance (or lack of) was a contributing factor
b) those that know that want to blame Airservices regardless of any other information that’s put infront of them.

He appears to be lined up with the 3,500ft step with Mt Gladstone at 2,504ft and 1,200ft+ terrain after that, so it seems incomprehensible that he would think he needed to be below 1,000ft and make it through. He only needed to be around 10nm right of track to avoid all of this hassle and stay up there for the next 80 miles and into clear skies. By the time he got there (to the class D) he would have been in 10k+ vis and would have realised it couldn’t be done.

Also, the Class C clearance was denied for the northern sectors, but what about the southern sectors... where is the transcript ASA and what was actually said, not a vetted summary?

If he was descending in cloud in an attempt to get to 1,000ft in order to comply with a direction from ATC some 90 miles from the destination, it simply doesn’t compute.

I feel like he’s gone on his own with his own descent to avoid CTA completely. It’s not uncommon, especially when you get multiple knock-backs.

Post #190 by Lookleft sums it up well in my opinion.

Having read the report, it seems fairly clear the PIC demonstrated a poor attitude to his role as PIC. This attitude not only claimed his life, but that of his son too. The view that a lack of a clearance being available was a significant factor in this accident is ridiculous. I'm no fan of AirServices, however it's not their role to fly the aircraft - that's the PIC's job!

There's a well documented list of hazardous attitudes (on pilot decision making) & this pilot seems to have had at least one or more of them.

I wonder if the tower meant to be proposing 1,000 ft coastal. I wonder if that crucial word was missed.. or missing?

Inbound IFR aircraft do not just 'pop up.' That's not how an ATC system works. They are known about well in advance through co-ordination from the previous controller. The Tower also gets a departure message from the AFTN network.

There is a culture of 'clearance not available' to VFR aircraft in Australian ATC. It's ingrained from day one of ATC training.

I have written to the ATSB requesting they make available the full transcript.

In the interests of transparency and safety they should not keep it secret.

I wonder if the controller has other class G workload that has not been mentioned in the report?

Dick, good for you. I too asked for the actual calls made during an incident that was published a few years ago. After a bit of tooing and froing, I was eventually ignored. Not good enough.

What he said exactly.

If he had filed a VFR flightplan, would that have helped ?
I envisage ATC would have had an indication of his intentions much earlier and had a heads-up.
What difference if any would flight following have made?

AIP ENR says that VFR flights intending to operate in CTA must submit flight details, with the preferred order of doing that being via NAIPS, then in writing, then by phone, and last by radio. It also says you should submit details at least 30 minutes before you expect to enter controlled airspace, and that 'Flight details submitted with less than the 30 minutes notification may be subject to delay.' Some places won't even let you in as a matter of course if you haven't submitted a plan.

If you don't customarily put plans in then using NAIPS can be a confusing and slow process, but once you get used to it, it's a doddle and just takes a minute or two to put a VFR plan in. You can choose whether you want to do that or not, but it's very probably going to make your life easier.

One of the more eye-opening experiences I've had over the decades was going for a jolly with an ATCer, in and and out of a capital city CTR, in his lighty. He was a friend of a friend and I wanted to hire his aircraft for a trip.

Amazing how flexible the system was for a call sign whose owner was known by the folks behind the Airservices mics. Simply amazing...

After that, I did a lot more submission of departure and inbound details by radio, and continue to do so, when that's convenient to me. I take the - perhaps naively quaint - view that a government organisation with "service" in its name and sends bills should give me the same level of service as one of its employees in the same operational circumstances.

"Some places won't even let you in as a matter of course if you haven't submitted a plan." Which just goes to show, and has become evident to me over the decades, that differences of outcome in like circumstances are sometimes the result of the personalities, pet peeves and local normalised deviations of those in the system.

Someone usually pipes up and says the people concerned could have been coordinating with other sectors or dealing with other aircraft with plan in the system or dealing with a bee-sting or heart attack, and that apparent different treatment in like circumstances is because the circumstances were actually different. Great: Let's hear what the differences actually were. I do not want to know what the Controller/s involved could have been doing; I want to know what they were actually doing, and why the clearance was actually unavailable. Two sentences.

The Mooney pilot in this tragedy did some stuff that I have never done and, touch wood, would hopefully not choose to do in the future. But, has already been pointed out, there's no explanation of the "why" the requested clearance into C was refused. That simply invites negative speculation about the ATC system and ATSB's motivations.

The failure to make the raw recordings of comms in ATSB reports is, in my view, inexecusable and, again, merely invites speculation about ATSB's motivations.

ATSB - like some in this thread - have no concern about throwing pilots under the bus. One wonders how the ANSP and regulator have reached operational perfection, when they are chronically dysfunctional organisations from a human resources management perspective.

That is one thing that is actually in the report:

At the time of the Class C clearance request, there was no other traffic below 10,000 ft in the Coffs Harbour airspace, nor were there any impending arrivals or departures during the time the aircraft would have transited the airspace. Within the remaining airspace being managed by the trainee and OJTI, there were five other aircraft being provided an air traffic service. Additionally, in the minute prior to receiving the request from VH-DJU, the trainee had completed handling a flight following request from a VFR aircraft.

Your reading skills are evidently better than mine, andrew. That's just the what they were doing, not why doing that prevented the grant of the clearance.

There is more

the trainee assessed that workload and priorities would not permit a clearance at the requested level
...
The OJTI assessed that the workload at the time of the clearance request was low, but the trainee being new to the role may have perceived the workload as higher. The OJTI also stated that while the trainee’s decision was conservative, it was appropriate
...
performance assessment reports and daily training records included debriefing and coaching comments emphasising to trainees and controllers to be cautious with issuing clearances below A080 through the [Coffs Harbour] airspace

One thing that I find interesting is that a trainee in their first week would be so quick to deny a clearance to a VFR aircraft. And it obviously did not come as a suggestion from the supervisor. They are being trained to deny VFR clearances.

We're trained to say "no" to many things if it will or may increase workload to a potentially risky level, doesn't matter if you're VFR or IFR. Direct tracking, tracking inbound across outbound routes, block clearance, airwork in the middle of arrival routes, etc & so forth. Not because we're lazy but because we have to be on top of the traffic & can't risk things getting too busy.

LB- No one has thrown the pilot under the bus, he quite deliberately walked out in front of it with his eyes only for the other side of the road. Even the simple act of crossing the road requires certain prerequisites to ensure a safe crossing. Ignore them or disregard them at your own peril.

I was speaking in more general terms about ATSB reports, LL. You know that.

But even in this case, I can understand why the communications with ATC may have confused the pilot into believing it was OK to fly at 1,000' or below on the track he ended up on. Whilst the pilot should have known the bus was coming, so should have ATC. Only in the Orwellian world of Australian aviation 'safety' can it make sense that there wasn't an added sentence in the ATC comms: "By the way, if you fly at 1,000' AMSL or below over there you're probably going to hit a mountain and die."

Centre seems to me to be able spend time telling IFR aircraft about blips and SSR returns miles separated but converging in G (which is why it isn't real G in Australia), and a lot of time telling blips and SSR returns in G that they are getting close ("two aircraft in vicinity of X. safety alert"). And it's great that that happens. But somehow it's OK for ATC to wash it hands on 'below 1,000' 'guidance' - or whatever that comms was meant to mean - because terrain clearance always remains the VFR pilot's responsibility?

"We're trained to say "no" to many things if it will or may increase workload to a potentially risky level ...". And there it is. We know who judges the potential. And, of course, there is no judgment of whether saying "no" merely moves the "potentially risky level" to an "actually higher risk level", because that's "someone else's" responsibility. And, on the basis of my experience, the outcome would have been different if the callsign had been an ATC mate's aircraft.

This is why in some places and times some grumpy arsehole will presumptively say 'no' to any 'pop up' request for clearance, no matter how busy or idle he is, because .... well, because he can and those pesky pilots should be taught that the AIP means what it says (the relevant provisions having, of course, been written by Airservices), but in other places it's obvious the person is trying his or her best to fit you in. That 'attitude' is felt and means something in some cockpits.

[T]he trainee assessed that workload and priorities would not permit a clearance at the requested level.

That's OK then.

Trainee: I'm just a trainee, this is getting complicated for me and I've been trained to say "no" in these circumstances.

Supervisor: Well done!

Of course every time someone gets a “no” it costs someone money, or in this case the ATSB has stated the “no” was a factor in the death of two people. I wonder if management at ASA collect data on the number of “nos” generated by their employees or just collect bonuses for cutting numbers of employees.

The one I really feel for in this mess is the wife & mother of the pilot & his trusting passenger i.e. her son (+ any other close family members & friends).

I'm reminded of the statement from one of the pioneers of the early days of aviation: “Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect”. Obviously, nothing seems to have changed in respect of this accident...

Sorry LB I missed the nuance in your post as it did refer to this thread

I take your point about whether a clearance would have been available had the trainee or the OTJI had known the pilot behind the call sign. Its an unfortunate aspect of human nature that mates are treated differently to others. Its not just ATC however. How many policeman have been let off a speeding fine with a nod and a wink. Someone I know is more likely to get the jump seat than a random from the Group.

The ability to just say no is also available to the pilot. Words like "negative" "unable" and "require" are all in the vocab and can be used by pilots of all levels. It took me three times on one occasion before the Departures Controller understood I was not going to take the tracking instruction that would take me and my 180 passengers and crew through a cell. When I was a freshly minted NVFR PPL coming into Canberra in a 210 with pouring rain and wisps of cloud in the hills ATC wanted me to take a vector towards Black Mountain Tower. "Unable" was the reply. They then wanted me to do an orbit. "Unable" was the reply. They then gave me a CTL on 12.

That flight taught me a lot about who is in control. Checking my log book I had a grand total of 170 hours. The current system is neither safe or perfect as any time I fly into Ballina reminds me. As it stands though Ballina suits GA as there is no Tower, Coffs suits RPT as there is a Tower. Which is safer? It depends on your perspective. In both circumstances the pilot has to operate in the environment that they are not comfortable with and mitigate as far as possible any risks to their operation.

Lead Balloon, we're not sitting in your aircraft so have absolutely now way of knowing what the view is like through your windscreen. You're flying an aircraft so the assumption is you're competent to do so & will advise if you're unable to comply with an instruction or need assistance. The pilot was in VMC when he initially requested clearance & would have remained so if he'd continued deviating right as he initially started doing. It would have added very little to his workload, no more than a deviation around a region of cloud would have.

The basis of your experience of a single flight with an ATC? Maybe, just maybe he applied a great deal of local knowledge to achieve the flight? Something a local operator would have as much knowledge of.

I confidently predict that we'd agree on the substance of most stuff, LL. It's the implementation that is the hard bit in the real world.

The key point you make is spot on:Pounds to peanuts that no private pilot licence trainee ever gets to practise that often these days, even as a mock exercise in the cockpit.

Yes it is okay. Or are you arguing a trainee pilot initiating a go around because they aren't comfortable should be criticised as well?

Pilots like to read a report and find something they would not have done so they can rationalize "That wouldn't happen to me." But it's not a controversial idea that accidents have a chain of causes that together led to the accident i.e the swiss cheese model.

The pilot's actions were analyzed in detail in the report. The Class C controller denying clearance was another link.

But I think there was confusion between the Class D controller and the pilot that was significant, and that wasn't examined well in the report.

• If the Class D controller had been alert to the pilot reading back something that wasn't intended to be a clearance it might have avoided the accident. That should be as big a red flag as an incorrect read back.
• If the Class D controller had been more specific about the clearance that was available, e.g. Woolgoolga - Bundagen Head at or below 1000 instead of just "at or below 1000 feet" the pilot might not have descended on track.

They weren't the only causes. But they seem significant enough to rate some examination.

Why would any clearance or instruction in any airspace warrant a VFR aircraft descending into IMC?

There were zero other aircraft in the airspace and the transit would have been less then 3 minutes. At what point does it become unreasonable to claim it is getting complicated?

It's always clear as to which posters are in the ATC system and who ain't.

Le P:

A student pilot deciding to go around, as a consequence of his or her own training and decision making in the specific circumstances of that decision, are making a decision for which the student and his or her instructor are responsible.

An ATCer saying 'no' to a request for clearance is, apparently, responsible for nothing.

Junior:

We get your point. The pilot was obviously a complete idiot who just didn't know what he was doing.

Andrewr's question says it all.

I don't disagree that on the surface it looks unreasonable but we have no idea what else was occurring. In the end it's up to the controller to make their own judgement & there will always be situations where "clearance not available" is an appropriate response. i.e. pilots have to plan for it. "Though shalt always issue a clearance" simply isn't possible.

As I keep saying it's no different to encountering weather or any other obstacle en route - you simply avoid it. Seriously, how is this any different?

Lead Balloon, the controller had no control over the actions the pilot took. How can they be held responsible for his lack of airmanship? Or are you arguing that if I say "climb to 9,000ft" & the pilot stalls his aircraft & crashes then I as a controller am responsible?

The report does go into some detail about what else was occurring.

Are you saying it would not be a considered a problem if a controller issued an instruction to a VFR aircraft to descend below the level of terrain? Is that a common practice?

I am not saying the controller did that - I am saying there appears to be confusion and the pilot might have thought he was instructed to descend to 1000'.

The controller who said "clearance not available" was the "C" controller - it's a totally separate issue to what the "D" controller did.

Gosh.

Just for transparency's sake, please declare that you have no involvement in this incident, either from a training or decision-making perspective, Le P.

You seem to me to be confusing - or perhaps (and sadly deliberately) obfuscating - a decision or instruction to do something, on the one hand, and the decision as to the way in which that thing is done on the other. And you may be confusing - or perhaps (and sadly deliberately) obfuscating - that which can be achieved safely (climbing to 9,000') and that which can never be achieved safely (tracking below 1,000' where the rocks are above that).

That is true. "Clearance not available" was a minor issue, but it seems to have touched a nerve as it frustrates a lot of people.

I think the confusion with the Class D controller was the worse problem. The efforts in the report to deflect attention away from the controllers and the lack of a transcript make me wonder whether there was a much more serious problem with the controllers than we are aware of.