ATSB Prelim Report Cessna Titan accident Lockhart River March 2020
 

https://www.atsb.gov.au/media/news-i...minary-report/

A well written ATSB preliminary report on the Cessna 404 Titan accident at Lockhart River 17 March 2020.

Included in the report was a photo of the instrument panel layout for that aircraft. Applicable rules require IFR charter category aircraft to have two artificial horizons. It is a given that they both must be viewable from the command seat without undue effort.

If the pilot's AH became inoperative in IMC while the aircraft was being crewed single pilot, it would be most difficult, particularly at night. to fly on the second AH, which in this aircraft is installed on the extreme right hand end of the instrument panel and well out of the normal eye scan of the pilot in the left seat.

The parallax error alone, let alone night instrument lighting, would make it impractical for the pilot flying from the left seat to consistently fly within current instrument rating tolerances.

This problem has been known by CASA ever since the installation of a second AH for IFR charter operations was mandated over 50 years ago. The problem has been conveniently ignored since then.

While the subject has no bearing on this specific accident, ATSB could do a power of good if they mention in their Final Report the incongruity of the positioning of the second artificial horizon in other GA types where fitment is mandatory.

I used to drive the C404, found the old Cessna truck to be a very stable IFR platform. In depth prelim report that one.

Yes. Kudos to the ATSB. A lot of fact in that report. Uncommon for a preliminary one.

I am amazed that there are IFR charter aircraft flying around without vertical guidance in the GPS.
The GPS approach with its 5 mile fix’s is a potential trap.

The other fatal accident at the same airport looked to be a step down too early on the GPS approach.

History repeats itself?

If you are flying with a GPS that does not have vertical guidance I suggest you get the boss to upgrade. More important than ADSB.

Absolutely correct Dick!
More importantly I doubt that the Cessna 400 auto pilot would have any capability for vertical guidance.
Sadly we possibly have a case here where the pilot did a great job in flight planning, plenty of fuel. Ticked the box for takeoff and landing weights. Viewing the photograph of the aircraft instrument panel, some nice equipment has been installed, let down only by a minimal auto pilot, which was probably great in its heyday; I doubt if it would really have the ability to 0.1nm tracking tolerance in gusty conditions.
For a Cessna 404 it was a low time aircraft by today's standards; I've seen Titan's knocking on the door of 50,000 hours.

In my experience there are very few IFR charter aircraft that have vertical guidance. Maybe the odd machine with a full G500 fit out or G1000. Very far and few between. Who is going to spend 200k fitting out a 30,000 hour 404 when a couple of G430/530 will do.

The graph displaying the vertical profile is a little alarming, Dick you might be on the money, or maybe he thought he was 1000ft higher. Judging by the fact he flew level below the MDA for a period of time might indicate that his forward visibility was zot however could see some ground directly below.

I don't know how we used to do App's pre GPS and survived? Until I drove heavy metal the GPS App's I used to do where done via the pitch wheel on the AP for vert guidance using basis ROD's and distances to go from each waypoint.
I suspect commercial pressure was some of the reason the guy ended up way behind the A/C.
The invention of satellite based navigation has been a godsend, it also has been another way of reliance on technology.

Interesting point if you’ve derived that from the track information, especially given that he misquoted his altitude to centre by 1,000 ft and seemingly corrected the call.

Quote:

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If the pilot's AH became inoperative in IMC while the aircraft was being crewed single pilot, it would be most difficult, particularly at night. to fly on the second AH, which in this aircraft is installed on the extreme right hand end of the instrument panel and well out of the normal eye scan of the pilot in the left seat.

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Flight Safety Australia Issue 130 Winter 2020 has just been published. Page 46 revisits the Monarch Airlines Flight OB 301 that crashed during a night circling approach to Young, NSW on 11 June 1993. The article by Robert Wilson starts with the opening paragraph "In the bleak midwinter" and continues with "The destruction of a regional airline 27 years ago revealed widespread shortcomings at the heart of Australia's regulatory system."

See: https://www.atsb.gov.au/publications...aair199301743/

The Chieftain, circling in low cloud and rain descended below the circling MDA and into terrain. Manoeuvering for a circling approach was made more difficult by a missing cockpit instrument the Horizontal Situation Indicator or HSI on the captains instrument panel. It was missing because the autopilot computer amplifier that powered the HSI had been removed for repair. This meant that the pilot in the left seat had to look over to the right-side direction indicator.

A pilot who flew a similarly configured cockpit as part of the BASI investigation reported increased workload from this distorted instrument scan, and reduced flight accuracy. A ramp check at Sydney Airport six weeks before the crash had discovered this and led to the resignation of the chief pilot but changed nothing else. The new chief pilot was unaware of the inoperative HSI.

The OP's comment re the bad positioning of the second (standby) artificial horizon on the far right of the instrument panel and out of direct view of the captain in the Cessna Titan that crashed at Lockhart River, suggests nothing has changed in terms of CASA learning from the bitter experience of the Monarch Airlines Chieftain accident 27 years ago.

During flight in IMC the artificial horizon is a vital instrument for obvious reasons. So is any other AH installed for regulatory reasons. Why place the standby instrument in such an out-of-the way position on the instrument panel that, if forced by circumstances to using it in IMC, it will create it's own hazard in terms of pilot instrument scan?

Not $200k. More like $27 k to buy and install a garmin GTN 650.

If a charter company can’t afford that type of capital expenditure necessary for basic safety they shouldn’t really be in business!

If we only spent our money on SBAS first instead of ADSB. Safety before efficiency? Not in Australia. Oh well, at least it should be here in 2023, then we can have LPV by 2025, some 20 odd years after the FAA, so much for leading the world;

https://www.ga.gov.au/scientific-top...te-positioning

Vref. I couldn’t find the cost benefit study on that link.

I'll only post this and mention it as food for thought for those out there who might find themselves in a similar situation, I'm no expert just another driver but I don't think it's a coincidence that he was at dot 0ft at 2nm when the runway was around the -2nm on the chart, if you move his second approach descent path forward on the graph showing his approaches both by 4nm they're quite similar and that slow turn to the left. Getting to MDA looking hard outside when you think you're over the top and 730ft can disappear real quick. Then add into the mix Morning flight, rough weather, Single Pilot IFR and 3 weeks since last flight and it stacks up the pressure on any Pilot.

I've spent a bit of time in very similar 404s in terms of Cockpit layout and tbh this one is not bad at all in my opinion, to what someone else mentioned previously about the AutoPilot the 400B's can be spectacular when looked after properly but that's a hard task as there are few around that truly understand them and if you're operating them I remember there being a chap over in WA (Perhaps Headland based now?) who is regarded as being the king, go see him, it's worth it or find SOMEONE who really knows them. Flying around GA like this is hard enough without adding that into the mix. If it was me I'd be asking the boss to put the money into getting that A/P done right rather than going from a 430 to a 650 for example, GPS's are great but having something that can reliably drive off them to reduce the load in Single Pilot IFR is priceless IMHO.

I don’t know about Australia, but a stock IFR certified Garmin G430W allows you to carry out an ILS or GNSS LPV approach. Vertical guidance to CAT 1 limits at many places in USA and here in UK.

The LPV requires WAAS or EGNOS SBAS..... I don't know if a similar system is available for Australia?

You can fly LNAV or LNAV/VNAV with BARO without SBAS though.

I think the argument is that BARO VNAV is more difficult to implement for lighties than LPV, which is just a [insert avionics manfuacturer's name] thingee installed. However, isn't an Australian WAAS being trialled now?

Vref+5 is spot on. ADSB proved to be an utter waste of money in terms of accident prevention as evidenced by the Mangalore crash and the loss of four lives, If that same time and money had been spent on proven WAAS technology, Lockhart wouldn’t have happened.

‘’So we still haven’t got WAAS because some Richard craniums in Canberra decided to wait for “second generation” WAAS? Not only have we lost lives in Aviation, we have forgone at least ten years of cost savings in the mining, agriculture and road transport sectors as well.

From the Geosciences website; they are as ponderous as an elephant and as brainless as a flea. Why didn’t we invest 20 years ago?

AsA should issue a disclaimer on ADSB ; “Although we made IFR aircraft fit ADSB, we don’t actually use it to provide separation. In addition, even though some VFR aircraft might have it, we don’t know where they are either, even if we do. In fact, outside radar coverage we don’t admit to knowing where anything is but we pretend that we do, sometimes. Furthermore, with the addition of new WAAS 20 year old technology, we will soon know exactly where you aren’t to an accuracy of ten centimetres”.

Thank god we didn’t let idiots like these design and construct other vital national infrastructure like our NBN, Oh! Wait!

Then all we need to do is micro-regulate as we have with ADSB, paraphrasing CAR’s: “ADSB for VFR is not mandatory but if you have it, you MUST have it switched on at all times and if it fails you are grounded after three days until it’s fixed. This is an offence of strict liability.” What a great invitation to fit new technology.

The first approach was stable and pretty good. Then possibly continued below MDA because he became visual and then initiated the GA when he lost VMC.
Thus it is mysterious that the second approach was flown the way it was. Easy, but pointless to speculate.

As Dick Smith says, the technology for vertical guidance is available, it should be mandatory.

Good point Dick but my question is this; why do GPS/GNSS/RNAV approaches have that 5nm waypoint at all, every pilot knows it adds confusion to the procedure, why not just have the IAF, IF and then nothing until the MAP?
Imagine doing a hand flown, single pilot RNAV approach in bad conditions, your brain is at or beyond its maximum capacity, over complicated approach designs don’t help.