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-   -   Mallard Down in Perth (https://www.pprune.org/pacific-general-aviation-questions/590122-mallard-down-perth.html)

Brian Abraham 16th February 2017 01:57


would the mallard have a stall warning system?
None mentioned in the manual.

Ultralights 16th February 2017 04:53

you dont need a specific stall warning system to know of an impending stall.

Capn Bloggs 16th February 2017 05:02

I don't know about that, Ultralights. If you don't often go out and do stall refreshers in XXX type, how would you know? The reason stall warning systems are put in aeroplanes is so the pilot gets advance notice of what is about to/may happen. If you know your aeroplane really well, fair enough, but if you don't or if it is a vicious bugger, then...

Turning onto final... even the experts get it wrong...

dhavillandpilot 16th February 2017 05:59

I'd be very surprised that it didn't have a stall warning, unless specifically certified without.

The Heron and the Dove in original form didn't have stall warnings as they were specifically certified by the UK CAA without any.

john_tullamarine 16th February 2017 06:04

Re artificial stall warnings .. it depends on the aircraft shake, rattle and roll characteristics.

Current light aircraft requirements at FAR 23.207.

UnderneathTheRadar 16th February 2017 10:17

Aerostars don't have them

oggers 16th February 2017 11:43


Re artificial stall warnings .. it depends on the aircraft shake, rattle and roll characteristics.
Yep. Eg C-152 requires a horn, PA-23 doesn't because it exhibits sufficient buffet.

Cloudee 16th February 2017 20:15


Originally Posted by Capn Bloggs (Post 9677662)
I don't know about that, Ultralights. If you don't often go out and do stall refreshers in XXX type, how would you know? The reason stall warning systems are put in aeroplanes is so the pilot gets advance notice of what is about to/may happen. If you know your aeroplane really well, fair enough, but if you don't or if it is a vicious bugger, then...

Turning onto final... even the experts get it wrong...

The expert would have had a stall warning in his Cirrus, but apparently still managed to stall it.

Brian Abraham 17th February 2017 00:37

Should anyone really, really want to know stall warning requirements, the type received certification September 8, 1947 under Transport Category, CAR 4a.

http://rgl.faa.gov/Regulatory_and_Gu...20Rev%2010.pdf

Edited to add: Had a look, no requirement I could find.

rich34glider 23rd February 2017 02:20

Having just read all of this I think the elephant in the room, as evidenced by the full right aileron & neutral rudder deflections visible as the aircraft started to spin, is the lack of effective spin training in GA - something that gliding (my world) still does very well. It seems like there are several reasons why he got into the situation but essentially he failed to immediately recover from an incipient spin/wing drop when very low. Sad.

djpil 23rd February 2017 22:34

CAR 4a specifies compliance with CAR 4b for transport category flight test requirements ... takes time to find it all ....

Clare Prop 24th February 2017 03:49

Training and stall warners aren't going to help you get out of a situation like that at that level. Disorientation would mean the pilot would possibly react inappropriately to visual and aural cues...if he saw or heard them. The series of decisions that took the aeroplane to that point are what caused the aeroplane to run out of numbers and stop flying.

rich34glider 24th February 2017 04:16

I agree that it was probably a series of decisions/circumstances that got him there Clare Prop (as in just about every accident) but I think it's unfortunate that GA training organisations spend so little time training for an instinctive & correct recovery for just this kind of scenario. With early recovery actions (right rudder, forward stick - no aileron - & full power) this may well have been recoverable in my opinion .. but yes, much better to not get in the situation at all. Humans will always make errors - best to minimise the consequences with appropriate training.

Sunfish 24th February 2017 22:13

Rich, conventional wisdom is that the practice of teaching stall/spin training caused more accidents, therefore it was removed from the PPL syllabus.

All you get is a demonstration with the admonition, "don't do this". The syllabus deliberately warns against teaching a student how to spin or practice a recovery apart from the "dancing on the rudder to pick up a dropped wing" BS.

I had to sign up for aeros to get taught to spin and recover. Still rusty on the process because there isn't an acrobatic aircraft for training within 100 miles of where I live.

Rusty1970 24th February 2017 22:33


Originally Posted by Sunfish (Post 9687182)
Rich, conventional wisdom is that the practice of teaching stall/spin training caused more accidents, therefore it was removed from the PPL syllabus.

All you get is a demonstration with the admonition, "don't do this". The syllabus deliberately warns against teaching a student how to spin or practice a recovery apart from the "dancing on the rudder to pick up a dropped wing" BS.

I had to sign up for aeros to get taught to spin and recover. Still rusty on the process because there isn't an acrobatic aircraft for training within 100 miles of where I live.

There are some interesting observations from driver training. You see the occasional A Current Affair story from some driver training organisation (or course with no commercial interest in the outcome...) saying "if only people were taught advanced driving techniques they'd know what to do if they lose control." Which on the face of it sounds sensible. Except that where it has been tried, from memory in Scandinavian countries, it had the opposite effect and fatal accidents actually went up. I understand mainly because it meant people learnt a skill then forgot in 3 months, but retained the overconfidence. Flying isn't driving of course and there is some opportunity to make people demonstrate the skills occasionally, but still...

Tarq57 25th February 2017 00:02

I think the better 'conventional wisdom' is to practice how to avoid getting in the situation in the first place.

I knew someone who was terrified of stalling the aircraft. Their partner, a very experienced pilot, had her fly it at normal cruising height all the way from departure to destination (a ~50nm hop) with the stall warning on all the way, so she could actually feel what the aircraft was doing, and how it reacted as it got a bit slow. This meant it took an hour to make the flight, rather than the normal half.

She reckoned it was a more valuable exercise for her than going up and practicing fully developed stalls. There's still a big place to practice stalls, though, as an exercise in why not to loose control in this manner.

Perhaps skid training in cars should be carried out using a similar philosophy.

I'm with Clare Prop: It was the decision making and general handling that was flawed, probably by the time the aircraft made its stall onset clear it was too late to do much.

How many of us, having gained the license/rating, then spend time on an ongoing basis, to play around with the behaviour of the aircraft near the edge of its envelope? For a lot, I think time and $ constraints would probably limit this sort of ongoing practice.

Clare Prop 25th February 2017 00:25

I was learning to fly (not in Australia) about the time that spinning was taken out of the syllabus and made optional. It was replaced by "slow flight awareness" pottering around right on the edge of the stall, horn blaring, keeping it in balance for a couple of hours from memory before you then did the fully developed stalls. People who wanted to do spinning went with the aeros instructor in the Chippy and did as as an aerobatic lesson.

Some interesting reading here:
An Evaluation of Stall/SpinAccidents in Canada 1999
http://www.richstowell.com/documents...a_TP13748E.pdf

In particular this part on Page 9 is relevant to this thread:
One feature that stands out in all except one of the 39 stall/spin accidents
examined is that knowing how to recover from the stall or spin was of no benefit to
the pilots in these circumstances. They stalled at altitudes so low that once the
stall developed, a serious accident was in progress.

rich34glider 27th February 2017 06:34

I still reckon some correct and instinctive recovery action may have saved the day .. certainly trying to correct the wing drop with aileron and no rudder guaranteed it was going in. Stick & rudder flying, just like was taught back in the good old days when Mallards were built.

rich34glider 27th February 2017 07:26

Even this Canadian research says "They (instructors) need to be able to teach their
students how to recover from these stalls as soon as the wing drops and before
autorotation develops" .. but everyone is saying the training is all too hard/not relevant .. confused!

Tarq57 27th February 2017 08:27


Originally Posted by rich34glider
I still reckon some correct and instinctive recovery action may have saved the day .. certainly trying to correct the wing drop with aileron and no rudder guaranteed it was going in. Stick & rudder flying, just like was taught back in the good old days when Mallards were built.

Even this Canadian research says "They (instructors) need to be able to teach their
students how to recover from these stalls as soon as the wing drops and before
autorotation develops" .. but everyone is saying the training is all too hard/not relevant .. confused!

I've done lots of stalls. Lots and lots. And a fair number of spins, in three different types, and I can't disagree with you. I used to practice stalls (and all sorts of other stuff) at least once a week, when I was flying lots. I was fortunate enough to be able to. I doubt the majority of pilots are able to maintain that level of currency.

I think, that in this kind of situation where there's been a stall/spin crash, that the pilots headspace was probably far enough away from what the aircraft was doing that the reaction time -even if stall recovery has been thoroughly taught - is likely to be excessive. By their very nature, it's clear these unintended events catch people by surprise.

I doubt that in this case recovery was possible once it was stalled. There may have been a brief opportunity before the wing started to drop, if the reaction had been correct and immediate. The out-of-spin aileron probably wasn't a mistake; it was more likely to have been a panic reaction, and by the time it was applied it was beyond recovery, anyway.

I believe that better training toward planning, and risk analysis regarding any proposed manouever, combined with some kind of resilience-against-surprise training might pay off better.

Quagmeister 5th November 2017 12:52

Still haven't seen the CASA Final Report...
But, my inexperienced/low hours personal opinion is...
- From a Human Factors angle, they were in danger the instant his lady occupied a Front Seat.
The concern about OAT/ engine performance was a distraction that possibly over-occupied the owner's mind. Understood in marksmanship, the wind can affect the shooter, more-so than the projectile.

A Pilot (PM) in the RH seat would have noticed the airspeed, and "mentioned" it... and if the PF doesn't react properly & immediately.. take control.
- A CFI did that to me once... still have the Lesson embedded...and tinnitus.

Seriously, later when taught to spin a full aerobatic 'plane, I'd add a quick touch of aileron to deepen the inside wing's stall and positively establish the spin.

Just like he did, sadly.

DHC4 16th March 2019 23:08

Report still not complete

https://www.atsb.gov.au/publications...r/ao-2017-013/

Updated: 25 January 2019

The investigation into the collision with water involving a Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 is continuing.

The final report has completed the drafting phase and is now undergoing an internal review.

Final ATSB investigation reports undergo a rigorous internal review process to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

Following the completion of the internal review, the report will be sent to directly involved parties for comment before the report is finalised and published.

Currently, the anticipated completion and publication date of the final report is during the first quarter of 2019.

Should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

On eyre 17th March 2019 05:53

Wow - so first quarter 2019 - someone is gonna be busy in the next two weeks ��

zanthrus 17th March 2019 06:23

Over two years and the buggars still haven’t finished a simple report? What the f@#k have the ATSB been doing?

601 17th March 2019 07:52


administrative reviews
I was under the impression that analysis of available evidence was what was required in a report.
What input does "administration" have?

Chronic Snoozer 17th March 2019 08:26

It shouldn't take two years to confirm what we already suspect. Dotting 'i's and crossing 't's means stuff all in the big picture which is what a report is about.

VH-MLE 18th March 2019 00:24

In the forthcoming coronial inquest for which the ATSB report will form a key component, it's all about dotting i's & crossing t's...

Squawk7700 18th March 2019 00:27

The NTSB appear to be quick at getting their reports out for the more simple incidents and they are also very quick to simply say “the pilot messed up” or
words to this effect. Perhaps Australia could take advice from them and grade the incidents accordingly.



DHC4 10th August 2019 23:16

We are now into August and it is still in ‘Final report: Internal review’ phase. Wonder why this is taking so long, have they forgotten about their first quarter of 2019 anticipated completion date.

Sandy Reith 11th August 2019 02:16

How long? Why so long?
 
ATSB was created as an independent Commonwealth corporate body by then Minister Albanese in 2009. As soon as this came about ATSB began to take on the familiar characteristics of this type of government entity. CASA is the ‘perfect’ example of the type, the incentives have altered. Make work prevails; economy, efficiency and timelines suffer. A little off topic but as an excellent example the photo illustrates the results of the hands off approach, the broken model of governance that’s common to CASA and the ATSB. A model that is increasingly a feature of the Commonwealth Government as Ministers inappropriately distance themselves from responsibility. Probably we don’t pay Ministers enough, Mr. Carmody gets twice as much as his Minister so who is boss?
Why have we lost hundreds of flying schools and maintenance orgs?
https://cimg9.ibsrv.net/gimg/pprune....1c0d6af4af.png
US:- $14.95 book with index. Start immediately with ins. rating, no grades 1,2,3.
. CASASTROPHE:- edited library, no index, $thousands, months or years, maybe permissible eventually, or maybe not like one well qualified instructor who put up $8000 ( flying school permission) application nearly four years ago, then gave up.

​​​​​​

Sandy Reith 11th August 2019 02:42

Why so long for a report?
 
In 2017 a few General Aviation types (and maybe others) including myself went to a conference at the Avalon Airshow to hear from Mr. Carmody head of CASA, Jason Harfield of Airservices and Greg Hood who is the head of ATSB. When Greg’s turn came to address us attendees he sported a hi-vis ATSB jacket and ran a video of the Mallard’s fatal last seconds as it plunged into the water. This video was on a loop and cycled there for us to see throughout the whole of Greg’s speech. Over and over again, surreal? Certainly bizarre say no more.

roundsounds 11th August 2019 07:06

It should make interesting reading.

Sandy Reith 11th August 2019 23:36

Report.when if.
 

Originally Posted by roundsounds (Post 10542265)
It should make interesting reading.

There’s not been any explanation for the full up elevator trim jacks position as discovered from the wreckage, none that I’ve seen to date. Certainly the current or previous official line about causation doesn’t seem plausible to some experienced Kingair pilots.

DHC4 19th November 2019 06:26

https://www.abc.net.au/news/2019-11-...eport/11718076

An investigation into the fatal 2017 Australia Day plane crash in Perth's Swan River that killed a pilot and his girlfriend in front of thousands of onlookers has suggested pilot error and poor procedures were to blame for the accident.

Key points:

  • The plane was taking part in an air show in front of thousands of people
  • It had completed two passes, but on the third it stalled at an "unrecoverable height"
  • A report found this third manoeuvre was against air show procedures


Pilot Peter Lynch, 52, and his girlfriend Endah Cakrawati, 30, died when their plane nose-dived into the Swan River during an air show ahead of the city's annual fireworks display.

Tens of thousands of people watched in horror as the Grumman G-73 Mallard flying boat banked sharply before crashing into the water.

A final report into the crash from the Australian Transport Safety Bureau (ATSB) has called for improved approvals and oversight for air show displays.

The report found the Mallard was supposed to conduct two circuits over the water following a Cessna Caravan aircraft being flown by a pilot who had experience flying in the air show.

"Following the Caravan was intended as a risk mitigator against the Mallard pilot's unfamiliarity with display flying over the Swan River," the report said.

RIP Peter

TWT 19th November 2019 10:39

Final report

Clare Prop 20th November 2019 00:57

The report didn't mention the video posted to Instagram, which shows a woman's hands on the controls just before the crash, she also seems to start in the right seat then move to the left seat.

Squawk7700 20th November 2019 01:01


Originally Posted by Clare Prop (Post 10622291)
The report didn't mention the video posted to Instagram, which shows a woman's hands on the controls just before the crash, she also seems to start in the right seat then move to the left seat.

Are you sure that was from the same day? Can you post the link here?

Clare Prop 20th November 2019 02:31


Originally Posted by Squawk7700 (Post 10622292)


Are you sure that was from the same day? Can you post the link here?

https://www.news.com.au/national/wes...d17229cd69d5c2

Squawk7700 20th November 2019 02:38


Originally Posted by Clare Prop (Post 10622291)
The report didn't mention the video posted to Instagram, which shows a woman's hands on the controls just before the crash, she also seems to start in the right seat then move to the left seat.

I wouldn’t exactly call that video valid evidence, as long as that aircraft type can be flown from the right seat. She’s simply done her best to make it look like she is flying the aircraft, presumably for the enjoyment of her instagram fans.

Clare Prop 20th November 2019 04:14

I would have thought that using this event to please followers on Instagram could be a contributing factor. I don't do Instagram but I understand there is a financial incentive to get your posts seen by as many people as possible? Maybe one more pass was needed to get the money shot? It shows she had her hands on the controls but had no qualifications to fly it and wasn't even supposed to be on board at all.


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