[Peetwo]

VH-ANK Lutana: 70 years on and the lessons lost? -    

Via the ABC News online...  

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Victims of the VH-ANK Lutana plane crash remembered 70 years on
ABC New England 
By Jennifer Ingall and Haley Craig
Posted about an hour ago



PHOTO: Pieces of the plane can still be seen at the crash site 70 years later. (Supplied: Libby McIntyre)

"It's very quiet. You can hear the wind in the background. There are lots of pieces of molten plane, bits of glass, aluminium ... no birds, it's just a quiet resting place."

These are the reflections of Libby McIntyre up high on the mountainside of the Liverpool Range in northern New South Wales, at the site where VH-ANK Lutana crashed in 1948, killing the 13 people on board the plane.

Libby McIntyre's grandmother Margaret McIntyre, the first woman to be elected to the Tasmanian Parliament, had her parliamentary career cut short when the Australian National Airlines plane she was a passenger on crashed into Mount Crawney near Nundle.

Ms McIntyre made the trek to the crash site with her niece Lucy Sharman to mark the 70th anniversary of the tragedy.



PHOTO: Libby McIntyre at the site where her grandmother was killed 70 years ago in the crash of the Lutana on Mount Crawney, near Nundle in NSW. (Supplied: Susie Bell)



PHOTO: Sir Rupert Shoobridge, president of the Legislative Council, with Margaret McIntyre in 1948 shortly after her election as Tasmania's first female MP. (Supplied: Libby McIntyre)

"To see still 70 years on all those little bits of metal, there's a wheel housing, bits of fuselage — someone else found a button today,"

"It wasn't eerie. For me it was the thought that it must have been terrifying for those people in the last minutes," she said.

VH-ANK Lutana crashed on a cold winter's night. There were no survivors, and to this day no-one really knows how the pilot got so far off course.



PHOTO: Search and rescue crews onsite in 1948 just days after the crash. (Supplied: Civil Aviation Historical Society Collection)

The flight from Brisbane to Sydney didn't arrive as scheduled at 8.55 pm on Sunday September 2, 1948. The alarm not raised by Sydney air traffic control until 10 minutes later.

The best source of the known details about the crash come from Air Crash Volume 2, written by the late Macarthur Job.

He wrote it took several days for the crash site to be located, after it was sighted from the air by another airline pilot, East West's Captain John Neuss, flying from Tamworth to Sydney.

A subsequent investigation found: "The aircraft had struck first the tops of 50 foot trees on the mountain summit, the initial impact being taken on the starboard propeller, the nose and wing tips," Mr Job wrote.

The plane then continued over the summit, and down the ridge for 400 yards, plunging into trees.

PHOTO: The wreckage of the plane lies in steep, wooded terrain in the Liverpool Range. (Supplied: Susie Bell)

"This more violent impact sheared off the port wing, overturning the aircraft, before it dashed itself against the mountain slope and burst into flames."

The burnt out remains of the Lutana were found 87 nautical miles north-west of its last reported position at Williamtown, leading investigators to conclude the pilot was not where he thought he was.

Captain John Drummond was in fact crossing the Liverpool Range when the plane struck Mt Crawney.

Mr Job wrote that an inquiry following the crash found the pilot and crew inexplicably diverted from their flight path, and were let down by navigation instruments and "untrustworthy maps."

The Department of Civil Aviation was criticised for "not using the modern scientific aids discovered and used during the war … such as radar."

The crash of VH-ANK Lutana was a turning point in civil aviation and led to many safety improvements.



PHOTO: The propeller of the Lutana was still embedded in the ground at the Mt Crawney crash site in 1968. (Supplied: Vic Hatfield)

Twenty years after the crash, John Neuss visited the site along with good mate Vic Hatfield.

Mr Hatfield said the site was still rugged and hard to find. The men flew over it in a glider the day before the visit to get their bearings.

Even 20 years later, there was still evidence of wreckage: the propeller, an exhaust pipe, even part of a wing high in a tree branch.

"A bit of sadness you might say, because 13 people died there very quickly," he said.

In 1983, the propeller was retrieved from the site and mounted as part of a memorial by the Lions club in the tiny village of Nundle.

Twists of fate revealed as relatives gather to remember



PHOTO: Former stewardess, the late Ann Shaw, at the Lutana crash memorial in Nundle. She narrowly escaped the fateful flight. (Supplied: Vic Hatfield)

There are tales of loss and luck among the people left in the wake of the tragedy.

The stewardess rostered aboard the flight, Brenda (Peggy) Wise almost missed it.

She met the plane just as it was taxiing down the runway in Brisbane, relieving Ann Shaw who had been asked by Captain Drummond to be on board for the Sydney leg because Ms Wise was late.

Many years later, Ms Shaw visited the Nundle memorial, saddened but ever grateful fate had stepped in that day.

Peg Higginbotham is the niece of Ms Wise who rushed so unwittingly to her death. Ms Higginbotham said her grandparents were so distressed by the loss of their 23-year-old daughter they raised Ms Higginbotham until she was six years old.



PHOTO: Peg and Richard Higginbotham reflect on the life of Peg's aunt and namesake Brenda (Peg) Wise who was the stewardess on the Lutana. (ABC News: Haley Craig)

"I was named after my aunt. I didn't replace my aunt, obviously, but my grandmother and grandfather obviously had a very huge hole in their hearts and needed some distraction," Ms Higginbotham said.

"So my aunt was always very present in my life, even though she died before I ever knew her."

Wendy Brown attended the service to mark the 70th anniversary. Her very existence hinges on the fact her parents, then newlyweds, changed flights at the last minute.

"I wouldn't have been born, my five sisters would not have been born, 13 grandchildren would not have been born," she said

"I'm here because they were not on that flight."

PHOTO: Sisters Tina and Margarite Van Andel unveil the memorial plaque with the names of the 13 people killed in the 1948 crash of the Lutana. (ABC News: Haley Craig)

Sisters Tina and Margarite Van Andel were not aware of the story behind their father Arthur's death on the Lutana until after their mother died. It was simply not spoken about.

"I think she was protecting us from any unhappiness, only focusing on what a good father he was, what a wonderful husband," she said.

Five of the crash victims are buried at the Tamworth cemetery where a new memorial plaque has been unveiled to remember all 13 victims.

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As was stated in the ABC's excellent commemoration article, although extremely tragic at the time, there was some very hard lessons learnt from the crash of VH-ANK which helped set the standard for aviation accident investigation for at least the next 50 years. 

Some would argue another CFIT crash 56 years later - ie Metroliner VH-TFU at  Lockhart River on the 7 May 2005 - marks the point in time when there was a serious decline in aviation accident investigation standards. Not because of the efforts of the ATSB tin kickers at the coalface but because of the bureaucratic butt covering from within the executive managements of both CASA and the ATSB...    

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Refer Ben Cook's PelAir AA series, from - HERE.   

&.. refer to ICAO's audit report from their Australian audit in November 2017  - http://auntypru.com/wp-content/uploads/2...t_full.pdf : 

AIG: Fully implement the ATSB’s action plan to ensure that all accident and incident investigation reports are completed within the established timelines. 

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So the Search for IP remains elusive...  

However if you were to believe the present ATSB CC HVH (HIGH VIZ HOOD); the serious decline of AAI standards has now been successfully arrested and will shortly be on the up  :
 

ATSB provides increased visibility into investigations



The ATSB is providing further insight into its investigation processes with the release of real-time investigation status information for all of its active investigations.

In addition to releasing the status of an investigation on its dedicated investigation web pages, the ATSB has also made available detailed information about its investigation phases and methodology.

ATSB Chief Commissioner Greg Hood said the changes were designed to provide a greater level of transparency into the work of the national transport safety investigator.

'The ATSB is a world class transport safety investigator and all of our investigations are undertaken in a meticulous and thorough manner, in accordance with both national and international legislation and standards. While our legislative obligations prohibit the release of restricted information during an active investigation, we strive to provide as much transparency as possible during an investigation.'

Mr Hood noted that the ATSB has traditionally provided more insight into its investigations than many international counterparts, particularly regarding the provision of estimated timeframes for each investigation.

'The dynamic and multifaceted nature of investigations can affect timeframes, which are always provided as an estimation.

'We understand that the length of time it takes to conduct a thorough investigation can sometimes generate frustration and uncertainty for directly involved parties such as next-of-kin, and for the interested general public.

'Australia actually performs very well against international investigation timeframes, particularly with  aviation investigations where our overall completion timeframes were assessed by the International Civil Aviation Organization as being around half of the global average.'
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Mr Hood said investigation timeframes are impacted by two primary factors—available resourcing and the unpredictable and often complicated nature of serious incidents and accidents.

'It is important to note that, even if the timeframe of an investigation is extended, if the ATSB discovers a critical safety issue during an investigation we immediately bring it to the attention of relevant parties to be addressed.'

To better reflect the dynamic and multifaceted nature of investigations, the ATSB has now amended its web pages to reflect an expected completion date as a quarter, rather than a month.
Those who would like to be kept informed of ATSB releases can subscribe via [url=https://www.atsb.gov.au/subscriptions/]the ATSB website.
 

   
Bear in mind that those HVH statements (above) were made over 8 months ago; so the question now is, has there been any real tangible improvement in that time? 

Apparently NOT! Well at least according to a small minority of IOS posting on this thread over on the UP : 

ozbiggles:

How unsafe is the ATSB?

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3 years to release a report on a loss of separation at Melbourne airport....3 years?

This is an ongoing issue with the ATSB who seem unable to release timely final reports into incidents that have all the information readily available and need urgent rectification.

The resolution to this event occurred within days of the event. Anything in this report is now 3 years old. How are we meant in the professional aviation space to rely on anything the ATSB produce when it happened so many years ago we have all moved on. It’s like a news report telling us who was PM 3 years ago.

AO-2015-084, released 06 Aug 2018

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patty50: 

Horrifying ATC. 

A trainee with 11 years experience overseas asking a 737 at 1,100ft to slow to minimum speed, who also mixes up call signs. 

Then an instructor telling pilots if they go missed to expedite said missed approach. Whatever an expedited missed approach is I don’t know, I do know mismanagement of energy during go arounds can be catastrophic (FlyDubai anyone). Coordinator then intervened and told trainee that the second 737 should go around. 

Authors seem confused about what a 90 degree turn is with a soft apportionment of blame to the EK pilots for following the taxiway lights. They mentioned a call to HQ and a please explain for why 777 pilots are following lights instead of cutting corners so ATC doesn’t look bad.

The entire report reads like a coverup for AirServices. I can certainly see why they sat on this for a while. No pilots to blame.

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QuarterInchSocket:

In my opinion, extremely unsafe.

i seem to recall that the prelim report for the mismanaged Emirates 777 go-around in UAE was released within 30days of the event and was of decent quality. If one expects level of quality from ATSB we’re dreaming.

I was waiting for a ground staff lightning strike report to develop some policy and procedures whilst operating on the ramp area during thunderstorms, some time back. Took 3 years to get to a final report after about 3 different delays (the prelim was just a statement of facts and took a year to come out)!! WTF! In the meantime, everyone is left vulnerable and exposed.

Much in the same way as you’ve said (if I’ve understood you properly), the final report said nothing of worth. No accountability! Nothing.

Useless bureaucrats!

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cattletruck:

In relatively recent times the Australian Public service has been besot with organisational paralysis. There is too much introspective focus by them on things that don't matter to us customers like HR, OH&S, LGBT+A-Z equality, etc, etc, which is allowing the boat anchors to thrive at being boat anchors while stifling the abilities of the doers.

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sumtingwong:

ATR pitch disconnect that put cabin crew in the hospital and very close to an airframe in the ground. The final report has been pushed back many times. The last promise of the final report? August 2018. So much for that. This event occured in Feb 2014. Over 4.5 years...yes years ago. 

Something stinks here.

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ZeroOneTwo:

There are plenty of mechanisms in the ICAO Annex 13 to get information into the public domain without delay.

This looks like a paper shuffling exercise gone wrong, but three years? There should be public accountability somewhere in the process...surely?

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73qanda:

With the examples given of delayed reports it certainly looks to be a safety issue. Lessons learned need to be gained before the incident is 4-5 years old that is for sure!

In the ymml loss of separation report we can see that both CASA and Airservices knew about the safety issue since 2011, words were said, hands were wrung but nobody wanted to actually make a decision that might be inconvenient.

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runway16:

It is not only the speed of delivery of accident reports but the accuracy of the actual reports themselves. In a number of ATSB GA accident reports that I have reviewed lately I can see errors of fact. To me they stick out like the proverbial. I have emailed ATSB re these items but no reply was the reply. The errors continue unchecked.

Some would say that they do not have the funding for more staff to clear the back log and to proof read the reports. Fine then perhaps ATSB should get less involved in the likes of a South African Convair accident or that of MH370. Both involved manpower and funds.

R16

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wheels_down:

Staff funding isn’t necessary the issue here. It’s the timeframe to get the new investigators trained up to the required standard which is multiple years. They are going through this currently. 


What concerns me is it’s taking multiple years for key safety alerts/fixes coming out of more serious incidents, by the time they have got to this point either it’s happened again (think AirAsia incident and incident) or loss of life. 

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Falling Leaf:

I think you will find that the investigators complete the report in 3 to 6 months. Then the upper management of ATSB, Airservices, CASA, the airline involved kick the report back and forth for the next 2-3 years with different legal threats until the final neutered report, which says nothing and blames no-one, is finally released.

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Lead Balloon:

But you can be sure that at Senate Estimates it will be all under control - short term issues that are being managed. Some huffing and puffing for show, from the usual duopoly Senators, and some genuine attempts to get to the truth from the non-major party Senators. 


The machine is broken. Once the machine is broken, it no longer has the corporate integrity to admit it, even if it knew it was broken.

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SIUYA:

Petropavlovsk …No-one is defending the ATSB Whyalla investigation report – it was less than competent.


But you draw a really long-bow in saying that everything after the Whyalla report was a fiasco.

Did you ever read the ATSB report into the 2003 IL-76 CFIT accident in East Timor?

That one was an absolutely top-class investigation report, and it was acknowledged in the ICAO Journal – see: 

https://www.atsb.gov.au/publications/investigation_reports/2003/aair/aair200300263/

https://www.asasi.org/papers/2004/Barter%20et%20al_IL76_%20ISASI04.pdf

http://www.aaiu.ie/sites/default/files/ATSB%20Australia%20Controlled%20Flight%20into%20Terrain%20Il yushin%20IL-76%20RDPL-34141%20Bacau%20Timor%20Leste%202003-01-31.pdf

https://www.flightglobal.com/news/articles/crew-errors-contributed-to-il-76-crash-183768/

The web has got MANY complimentary articles about that investigation. It set the scene for a lot of benchmarks on HOW a complex investigation COULD be managed in a remote location with LIMITED resources EFFECTIVELY to provide a top-class result.And, the report was issued in less than a year of the accident. So, with the right folks, ‘yes’, the ATSB was good at what it did.

Now? Not so sure.

But maybe you need to consider AND acknowledge that the ATSB DID have some very competent investigators at the time of the Whyalla report, who really DID know what they were doing, and ask WHY that’s no longer the case, instead of throwing shit at the good guys who left and then addressing WHY they left? I know a few of them and they are VERY bloody good operators...….and they still work in PNG!

You refer to the PNG AIC…..seen the good work that outfit is doing lately Petropavlosk? Somehow I don’t think so.

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Lead Balloon:

Yep - the ATSB used to have a critical mass of competent personnel, competently led (although, in the case of the original Whyalla report, no one with sufficient competence in piston engine physics and chemistry).


ASTB no longer has that critical mass. Just like CASA.

Although it’s true and nice to say that there are some ‘really good people’ working in these organisations - some of whom I count as friends - the fact remains that the organisations are busted. The machines are busted. They are less than the sum of their parts and - what’s worse - governments no longer know how to fix them.

Hmm...I feel an O&O thread update coming on...


MTF...P2