Good catch ATSB
“However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.”
It is good to have a puzzle solved. It was always suspected that there was not enough ‘space’ (height, time and distance) allowed for the manoeuvre; always looked ‘cramped’ and indeed needing ‘higher bank’ at low levels to fit.
“Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft.”
There was a suspicion that the pattern flown was a ‘requirement’ - good to see that ruled out, fairly and reasonably.
“Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.”
There’s not too much CASA or ATSB can do about ‘attitude’ or ‘professionalism’; display flying is a discipline, not a Sunday pre lunch ‘jolly’. The air show accident statistics back up the need for both.
“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.
Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.
Spot on.
“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”
In CASA’s defence – there is not too much more they could have done, than they did to prevent this accident. No amount of paperwork, improved or otherwise could have changed the outcome. A poorly flown pattern, low, slow, steep turns close in and tight? Tricky stuff. Had the pilot mentioned his true intentions to CASA, I reckon they may have had somewhat to say about the notion like – “just leave your licence on the desk”. As I remember it, there was some discussion about ‘experience on type’ and a bit of push and shove for the approval to operate being issued. (P2 – was that an Estimates thing?). Tough on the Regulator – miserable bastards for a Nay; in the gun for a Yeah. They gave the benefit of doubt – and end up having to provide more ‘paper-work’ and more restrictions. Sometimes, (rarely) I feel a modicum of sympathy for the CASA crew at the coal face. Tough call for CASA, decision made with the best of intentions, within the rules; can’t blame ‘em for the result (IMO).
Sad event, nicely done ATSB,
Toot – toot.
“However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.”
It is good to have a puzzle solved. It was always suspected that there was not enough ‘space’ (height, time and distance) allowed for the manoeuvre; always looked ‘cramped’ and indeed needing ‘higher bank’ at low levels to fit.
“Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft.”
There was a suspicion that the pattern flown was a ‘requirement’ - good to see that ruled out, fairly and reasonably.
“Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.”
There’s not too much CASA or ATSB can do about ‘attitude’ or ‘professionalism’; display flying is a discipline, not a Sunday pre lunch ‘jolly’. The air show accident statistics back up the need for both.
“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.
Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.
Spot on.
“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”
In CASA’s defence – there is not too much more they could have done, than they did to prevent this accident. No amount of paperwork, improved or otherwise could have changed the outcome. A poorly flown pattern, low, slow, steep turns close in and tight? Tricky stuff. Had the pilot mentioned his true intentions to CASA, I reckon they may have had somewhat to say about the notion like – “just leave your licence on the desk”. As I remember it, there was some discussion about ‘experience on type’ and a bit of push and shove for the approval to operate being issued. (P2 – was that an Estimates thing?). Tough on the Regulator – miserable bastards for a Nay; in the gun for a Yeah. They gave the benefit of doubt – and end up having to provide more ‘paper-work’ and more restrictions. Sometimes, (rarely) I feel a modicum of sympathy for the CASA crew at the coal face. Tough call for CASA, decision made with the best of intentions, within the rules; can’t blame ‘em for the result (IMO).
Sad event, nicely done ATSB,
Toot – toot.