Coroner not happy with ATSB
 

A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy.

Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."

“One other obvious problem with the report … is that there is no indication of the author or author’s qualification to express the opinions and conclusions contained in it. In fact, there is even no indication as to the identity of the author or authors."

Mr Cooper said: "Perhaps most surprisingly, despite the fact that it was investigating an aircraft crash, the ATSB report does not appear to attempt to establish, at all, the reason for the crash.


https://www.abc.net.au/news/2022-08-...rash/101370152

https://www.atsb.gov.au/publications...r/ao-2018-078/

What else did the Coroner expect? ATSB had little data with only ADSB track, altitude and ground speed.

You do realise that we used to have an investigative body which was able to conduct very good investigations into aircraft accidents, without any ADSB track, altitude or ground speed data?

Coroner’s Findings, see para [65] onwards for the conclusions re the ATSB report

But he then goes on to say [Paragraph 85:] "In my view, evidence enables a conclusion that until the very last moment of the flight, immediately before colliding with the Western Portal, Ms Walker remained in complete control of her aircraft. What happened in the immediate moments before colliding with the Western Portal can only be speculation." In his view?? Is he an aircraft crash investigator now?

I'm not saying it happened this way, but if you want to "speculate", what if she had issues with the autopilot at precisely the wrong moment like the young girl in the C172 that crashed into a hill NW of Melbourne not so many years ago?? It's the ATSB's job to rule that out.

You need also to read paras 17, 18, 19, 39 and 40.

All day, nearly every day, coroners deliver findings as to causes of death in circumstances in which the coroner has no personal expertise. That's their job and that's why they like to be assisted by people with expertise in the subject matter.

Aaaahhh, Tasmania, on a good day it's Gods own, on a bad day it's Hell, except for the temperature. I'm afraid the young Lady died of her own hand, in as much as pressing on into weather, anyone who has flown in the place will have their story of trying to operate in VMC. Used to regularly fly Hobart to Melaluca, a strip just south of Bathurst Harbour, very rarely went direct, only once that I recall in fact, always tracked down the east coast, then along the south to destination. Once had to do a semi circumnavigation of the state to get from Strahan to Hobart, up the west coast, along the north to Launceston, down the valley to Hobart. Refueling at Queenstown one day and a Cessna single landed with two lads and girlfriends with shrubbery hanging, from Hobart and had got caught in a valley, hit the trees on climb out, aircraft undamaged, though their psyche must have taken a hit. Did a lot of work with survey teams, land on top of a mountain in clear weather then have to pack up and make a run for the aircraft when a cloud cap suddenly formed, hovering down the side of the mountain with eyeballs on stalks until getting VMC. Glad to leave the place, only because of the flying risks that were difficult to outflank.

Once took a week to wait out weather before we could get into the high country south west of Cradle Mountain to rescue a climber with a broke back. Closest we could land was about a mile away and carried him on a stretcher, flying home I found myself covered in blood, leeches had snuck in everywhere.

though their psyche must have taken a hit.

Can be a worry when that doesn't apply.

A case in point. Years ago, up at Kyneton, doing some engineering work ...... Cloud base a whole lot lower than I would have chosen to fly in VFR. Along comes a little single from a well-known and large training organisation in NSW. Low circuit and landing. Some youngsters clamber out.

I had a relaxed natter with the pilot. Now we all have frightened the living bejezus out of ourselves on multiple occasions in nominal VFR operations. My prime concern talking with the young fellow was the observation that he was quite relaxed about the preceding flight - what should have frightened him witless had had no apparent effect on him - big worry there. Turned out that his father was one of our 767 captains so I had a natter with dad when convenient and related the tale so that dad might be able to have a beer and a chat about this and that with the son. Father was quite grateful for the opportunity to be able to point out a few things to the youngster.

How we actually managed to get through our first 1000 hours, frightened but not scratched, often causes me to shake my head .....

that's why they like to be assisted by people with expertise in the subject matter

My concern, reading the reported tale, is that one might wonder whether the coroner might have done better insisting that he actually did have such expertise available to him during the coronial ? His reported comments suggest otherwise ... ?

Its important to read why the coroner found the report lacking, towards the end. Its more about the speculative aspects that poke blame on Par-Avion, CASA and the BOM, without any evidence to support the assertions. Considering the amount of flight data the coroner seemed to have including aspects of attitude at impact I can see why he was having a go at the ATSB for not finding a cause.

After all the ATSBs job is to investigate the cause of an accident. The coroners job is to find cause and factors leading to death (in short).

The coroner was obviously intrigued by whether there was some cause outside of 'pilot misadventure' that needed to be looked at. With statements along the lines that Par-Avion 'encouraged' pilots to depart in marginal to poor conditions sort of hints that the company and others may have shared some blame. Effectively getting to the end and saying your report wasted my time, do better next time.

There may have also been some questions over survivability and the delay in reaching the site, which I think were definitively answered in that report.

I had skimmed the ATSB report AO-2018-078 some time back prior to reading the ABC news item with the coroners fairly scathing remarks about the report. I have taken another look at what ATSB wrote and, without reading everything, I still think it seems sensible and makes a reasonable assessment of what most likely happened, including the 'reason' for the crash: "While using a route through the Arthur Range due to low cloud conditions, the pilot likely encountered reduced visual cues in close proximity to the ground, as per the forecast conditions. This led to controlled flight into terrain while attempting to exit the range". Not sure what more was expected or was possible for ATSB to establish?

It is also noted that a draft of report was provided to Airlines of Tasmania, CASA, BOM and others and that in response submissions were received from all three and the UK AAIB. Those were reviewed and, where considered appropriate, the report was amended. So the report has some independent review. Perhaps ATSB should include relevant state and territory coroners in the release of draft reports where accidents involve fatalities so that coroners have an opportunity to comment before a final report is published by the ATSB? [Update: ATSB did just that for the report into the C130 N134CG crash at Peak View: "draft report was sent to the NSW State Coroner for information"].

The list of witnesses at para 17 seems to include some people with considerable aviation expertise, though it might be argued some of them had at least apparent conflicts of interest. I think 43" makes a good point: The statements in the ATSB report naturally raised issues and questions beyond just pilot error but the coroner had no witnesses independent of the operator to give evidence on those issues to help answer those questions. And, for all the coroner knew, the author/s of the ATSB report could have been the Year 10 work experience kid/s. The operator naturally argued that there was no credible evidence before the coroner to support findings equivalent to some made in the ATSB report.

The ATSB's usual practice of refusing to get involved in coronials has its disadvantages...

The list of witnesses at para 17 seems to include some people with considerable aviation expertise

I don't dispute that although it would be useful to review what those witnesses may have had to say in detail ?

I find paras 32, 33, 35, 40, and 59 somewhat rather more interesting than para 17 ?

Most of us, in our earlier flying days, have been in circumstances, whilst flying "VFR-ish", which might be similar to what this pilot experienced. Most of that group managed to survive the experience, often more by good luck than good management, I suggest ? A few such frights and the wise VFR pilot builds in a bit more conservatism to the in-flight decision-making processes. Personally, I think the long-running PNG thread on this site ought to be mandatory reading for all newbie VFR pilots .... we might not have that sort of tiger country on the mainland but, in patches, it can still kill one in the blink of an eye should one let one's guard down in adverse weather ...

It may be possible to get transcripts of the hearings or copies of affidavits made, but I haven’t confirmed that.

My reference to para 17 was merely in response to your expressed concern about the qualifications of witnesses.

Many of the other paras were ‘interesting’, including the specific ones you mentioned, in relation to what the coroner found as a matter of fact. Very tragic and so avoidable in fact (in my view). The pilot’s experience on the aircraft and route flown should have been enough (in my view) to enable to the pilot to make, and be confident in making, the call to turn back/avoid or whatever..

I think that is what the Coroner was getting at with some of the comments. The ATSB included in findings/recommendations that more information to pilots should have been available, but in this case it would probably have not altered the outcome as the pilot was significantly experienced on the route and familiar with weather patterns. The same could be said of commercial pressure or 'encouragement', this pilot would most likely have known when to say no in most occasions except this one. The coroner seemed to think on evidence that it was a reasonable decision for the pilot to depart and follow the route they did on meteorological information available. And the part about a recording device, really, what sort of recording device are we talking about, they already know the flight path and attitudes at impact. Are we talking about a CVR in a single pilot aircraft just in case the pilot is talking to themselves, or are we talking video recordings, which has always been a big no-no among pilot groups. FDR and CVR will most likely not shed any more light on what happened, it definitely will not really show much in the way of weather outside reducing visibility, unless it was heavy rain or hail. Its nice to mention these things, but when do you stop before getting to the point that they say they need some form of 'time machine' so they can go back and watch what actually happened.

I think the critical aspect is focused on the 'Crash Investigation Report' being turned into a safety advisory and not focusing on the crash and it's actual cause, rather proceeding directly to identify deficiencies within the company not directly related to the accident.

The coroner seemed to think on evidence that it was a reasonable decision for the pilot to depart

I'm sure the coroner approached the question in an appropriate and reasoned manner for the role and consistent with whatever evidence was led and background knowledge.

Unless it's a case where blind Freddie can see (or should have seen) that it's a no-go situation without any redeeming option, I have no problem with a pilot's heading off to have a look see. We've all done that, have we not ?

However, the problem potentially then arising is the flight management question/strength to make the call in marginal conditions to do something different rather than just continue with crossed fingers. It's a bit like checking - either do really well so it's a programmed pass, or really bad so it's a programmed retraining or another check ride, but don't pussyfoot about on the yes/no fence line so I have to make a decision. I wasn't there so I have no idea what the pilot specifically did or didn't observe on the day. Just a dreadful waste of a young talent and life, with the benefit of 20/20 hindsight, that she chose the course of action she did ?

A bit like the two young fellows on the east coast, years ago. I didn't know them but knew one's mother and her parents well when I was a child from family friendships so it was a bit close to home for my liking.

Most of us have been there, done that, got the tee-shirt and, somehow, managed to survive the experience with a greater or lesser degree of terror at the time. The eternal operational question remains - how to put older heads on younger shoulders ?

I think the real key is why did she cross the 'portals'. The statement from the helo pilot gives some clue that he could see light through the gap. This is probably what the Islander pilot saw as well, bit of light, the mistaken belief that beyond the saddle was wide open clear air, combined with the web cams at Bathurst Harbour showing OK conditions once she had passed that point. After crossing that saddle and it closing in behind then there are very few options, so in a way its a critical location. She obviously tried south, then north to no avail and then tried to get back through the saddle. Once she had crossed the 'portals' her fate was sealed, that is the critical point in this, from there she was trapped in a weather bowl with the choices being land on whatever suits or try to fly through some bad conditions to freedom.

The point here is that if flying through tight spaces, make sure when you pass critical locations that you are certain that the path ahead is clear and that the pass behind is not subject to rapidly closing. I think here the idea that there was multiple options to use after the portals gave the pilot some confidence to continue through a very small gap and then found out that in some rare circumstances all routes out of the next valley become blocked.

... bit of light, the mistaken belief ...

Hence the value in newchums' having a think about the operational wisdom contained in the PNG thread ...

First time I got suckered into the gap trap was donkey's years ago from BK heading over the hills west as, very much, a newchum. Got myself trapped but got out of it. The lesson never left the forefront of my thinking in VFR bad weather flying. Subsequently, I wanted a big gap to continue and a rear window to keep an eye on what was going on behind me.

And the sucker holes are everywhere, from saddles in mountains to small holes in overcast you think you can safely climb through. To the gently lowering cloud bases that lure you into a corner and when you turn around its lower again. Maybe VFR pilots have to live with idea that cloud is a living intelligent force actively trying to kill them, so stay well away from it and treat it like an apex predator. It can even spit rain and hail on you from afar to confuse the unwary horizon pilot.

And the sucker holes are everywhere,

.. isn't that the simple truth. I was lucky, I did my PPL on an ATC scholarship. Finished min time and Jack/Stan (RNAC) figured we should spend the remaining 15 hours or so (before the RAAF found out I'd finished the licence) under the hood doing circuits and aerobatics limited panel. Helped to save my bacon on a few occasions since ... That first trap for me saw me up into the scud on the clocks, stall turn reversal and, fortunately, the way in hadn't clagged in totally. Probably would have been a different ending had I not had some I/F aeros behind me and not all that long before.

3 lost west of Brisbane Monday 29-8-22 - PPRuNe Forums

Post 6 provides some sobering photographs of weather.

The photos may not be what the pilot saw but, in terms of this thread, are very illustrative of sucker bait situations going over/through areas of hilly terrain. A slight change in temperature or wind (or a couple of hundred feet increase in terrain elevation) and photo 1 can turn, very rapidly, into something like photo 2.

(I would hope) it is not likely that anyone would push on in conditions of the second photo, but the first is just so typical of what can tease the (inexperienced or overconfident) pilot into a dead end trap from which there is no way out.

The coroner is looking at the cause of death. The ATSB is looking at the cause of the accident. Different perspectives of the same event so for the coroner to criticize the ATSB report for issues not directly involved at the time of impact suggest a fundamental misunderstanding of what aviation investigations are for. BTW Mr/Ms Coroner, ATSB reports never have the IIC name on it.

The coroner is inquiring into the nature of the death, how they died and factors that led to that. It's not just about 'cause of death', cause of death would be directly related to the impact sequence. How the person came to be in that situation asks a few more questions and does intermix with the ATSB accident report. A few items in the ATSB report seemed to imply there was contributing factors beyond the pilot flying into IMC inadvertently such as possible commercial pressure to 'have a go' and so on, which could have had Worksafe implications and such. The ATSB report does diverge from the accident investigation into a more general investigation into the company and CASAs handling of the company, which is where the Coroner has picked points on about what it has to do with the accident in question.

Its called Organisational factors. The ATSB and others have been looking at such things for a very long time. The Chieftain accident at Young was one of the first accidents that looked beyond the immediate impact of plane against planet. I don't expect a coroner to include that but they shouldn't be criticizing the ATSB for doing so. LB can clarify the role of the Coroner as to whether they look at the "nature" of the death or the cause of death. IMHO a significant difference in meaning.

If you read the coroners report it outlines what he is looking at with reference to the coroners act. His comments WRT the ATSB is more about the evidence the ATSB had to make such accusations, more so the lack of any evidence provided regarding such things. Cause of death is straight forward what killed the person, from a medical point of view.

In short the ATSB made a statement to the effect that Par Avion "encouraged" pilots to depart in marginal weather conditions. This would have peaked the Coroners interest given the lack of evidence provided as it becomes an accusation of possible workplace issues, that is, was the pilot in that location due to being pushed beyond their will by their employer. The other issue identified was the lack of operational information given to pilots, however the coroner suggested that the pilot was reasonably familiar with the route so the lack of printed material was not relevant.

I'm well aware of what organisational factors are, but it muddies the waters in an 'accident' investigation. Possibly it should have been investigated separately.

Wrong. This is what the report actually stated:
The evidence comes from pilot interviews none of which are going to be made public. It is also quite clear that it comes under the heading of increasing risk and was not a contributing factor. The purpose of an ATSB report is to investigate an accident so that others may possibly learn from it and avoid doing something similar. The coroner in this case does not seem to understand that.

Then you don't understand the purpose of an ATSB investigation either. Its all part of the investigation. To suggest that an investigation of organisational issues should be separate from the accident investigation is ridiculous. The ATSB are criticized for taking too long as it is let alone having to produce two reports for the one occurrence.

I suggest you read the coroners report in full and if you have any further questions as to why he came to those conclusions contact him directly. I'm not him or his proxy i'm just parroting what is contained in the report.

From section 28 of the Tasmanian Coroners Act:

Thanks LB. They must find the cause of death. They may comment.....

I would have thought that this entails the coroner digging a bit deeper than the collision with terrain:

In Para 86 he makes it quite clear that there was nothing that happened that could be prevented into the future therefore meeting his obligations under Part 2 of Section 28. IMHO there is more to the coroner's objection to the ATSB report than meets the eye. The coroner was basically saying that it was all an unfortunate accident (which it was) and that the pilot's employer had no role in what happened. The ATSB were simply stating that there could be improvements made to the companies SMS beyond just relying on incident reports. They were not blaming the company for anything. I remember after the Mt Hotham report that the Chief Pilot engaged the services of a high profile lawyer to trash that report. In an unusual step the ATSB released a supplementary report which provided even more information about what the accident pilot had done that day. The high profile lawyer didn't have a lot to say after that. I am not alleging anything about why the coroner felt the need to trash the ATSB report but it says more on what improvements could be made to improve the safety of operations to that part of Tasmania than the coroner does.

.. and another pertinent video of perhaps what not to do ....

https://www.pprune.org/rotorheads/64...g-terrain.html

In addition to the video in post #1, do have a reflect on the story in the video at post #48 in the same thread. If the final few seconds of the clip, post flight, don't have you involuntarily sucking air in through your teeth, then you are cooler and more collected than most of us, I would opine ....

That video really shows how quickly it can go from "I can see enough" to "Crap I cant see anything" and you can see the panicked response from the pilot. So lucky they survived...

There's enough of these vids to make a good training package for all pilots to watch at a very early stage.

..and another link from the other thread, thanks to Capn Rex Havoc.

By my reckoning, the glider pilot (having entered serious IMC at around the 2:30 mark) took about 10-15 seconds to lose it totally .... unless you are an experienced I/F pilot with, at the very least, limited panel instruments, VMC into IMC near invariably works out to be a bad outcome. That this pair survived involved nil management and an incredible amount of good luck.

Most of us who are rusty I/F pilots treat it with the same (very) healthy respect (fear ?) ...

(Can't say that I was impressed watching the slip string's gyrations along the way .... seems a lot of folks still view the rudders as footrests.)

I have no first-hand knowledge of the course of the coronial proceedings as a result of this tragedy.

However, I’m completely unsurprised that the relatives of the deceased pilot or someone else brought the coroner’s attention to the ATSB report. The average punter would make the reasonable-though-naive assumption that the whole point of the ATSB’s existence is to find out why an accident occurred and that task would involve some deeper analysis beyond pilot error - given what we’ve supposed to have learned about these issues over decades.

But that seems to me to have presented the coroner with a conundrum: What evidential weight should be put on the findings and expressions of opinion contained in the ATSB report? For the reasons explained by the coroner, the answer was: Little-to-none. Absent some statements in the ATSB report as to the qualifications of the author/s and the basis upon which the findings and opinions were based, and absent someone from ATSB giving evidence at the inquest, that answer is pretty unsurprising to me. So the coroner is left with…

The relatives of the pilot who died in this tragedy aren’t the first and won’t be the last to be left bewildered - sometimes worse - at what the ATSB (and CASA) do and how they go about doing it.

So what did the coroner come up with that the report didn't? What I read of the coronial report was that he was exonerating the company of any responsibility and simply stated that it was an unfortunate accident. The ATSB report went into the SMS of the company and that their system could be improved. They also come up with the same conclusion but with more aviation specific terms. ATSB reports, other than research reports, never have the investigator's name on it so I don't know why that is even mentioned as an issue. Its up to the coroner as to whether they accept a report or not as the basis of their findings. This one decided to not accept it ,as they are entitled to, but then took the extraordinary position to diminish that report and the ATSB because he said it had no value to him. Yet did not come up with anything that was significantly different except for stating that the company had no responsibility. The ATSB were investigating yet another CFIT or VMC into IMC accident trying to lay out why it might have occurred other than blaming the pilot. What I got from the report was that the company were encouraging (not forcing) pilots to have a look at the conditions and making their own judgement. Their assessment of the risks and their ways of dealing with it can be improved. Of course it can be improved as a pilot employed by them died. That the coroner did not even address that issue but stated that they couldn't have done any better suggests a complete lack of understanding of the purpose of an ATSB report. The company can wash its hands of the whole affair. Hopefully the family can accept that it was an unfortunate accident which makes the coroner's report worthwhile. As far as preventing further VMC into IMC accidents the coroner's report is as worthless as he considers the ATSB report to be. In years to come it will be interesting to compare the Qld coroners response to the ATSB report into the recent accident near Wivenhoe Dam. Reading some of the comments on that thread and how some pilots think they can beat the system with fancy avionics I think the coroners and the ATSB will be kept very busy. Lets hope they can learn to get along for the victims sake.