Accidents - Domestic
730 report tonight: - Confused

Quote:Father demands aviation regulator CASA 'get off its butt' after second fatal Angel Flight crash

7.30
By Angelique Donnellan

Tue 25 Jul 2017, 10:10pm         
r videos
Video: Father demands safety be improved after second fatal Angel Flight crash (7.30)

A man left devastated after his wife and daughter were killed in an Angel Flight crash in 2011 is demanding safety be improved after a second fatal Angel Flight accident last month.

Key points:
  • Angel Flight co-ordinates free flights for country patients for non-emergency medical treatment
  • Two fatal crashes involving Angel Flight journeys in the last 6 years
  • Charity's flights not covered by CASA's commercial regulations because they are private
  • Father of girl killed in an Angel Flight crash calls for consistent regulation of charity flights
Len Twigg said the latest crash had brought back horrible memories of when his wife Julie and 15-year-old daughter Jacinda died six years ago.

Jacinda Twigg was being treated for juvenile arthritis in Melbourne but on a return Angel Flight to Nhill, in country Victoria, the plane came down.

Pilot Don Kernot also died.

An investigation found low cloud, rain and fading light made the pilot disorientated and lose control.

"I was diagnosed with PTSD pretty early on, severe depression," Mr Twigg told 7.30.

"I can understand why some people would choose not to be here anymore, how they couldn't deal with it, but I've got three other beautiful kids and I wouldn't do that to them."
[Image: 8723794-3x2-700x467.jpg] Photo: Jacinda and Julie Twigg in Melbourne just before they boarded the doomed Angel Flight in 2011 (Supplied: Len Twigg)

Mr Twigg could not believe it when he heard that another Angel Flight had crashed in South Australia's south-east last month.

Emily Redding, 16, her 43-year-old mother Tracy and volunteer pilot Grant Gilbert all died.

Emily had anorexia and was using Angel Flight to get to a medical appointment in Adelaide.

"It certainly rekindled everything," Mr Twigg said.

"Then I saw the photos and I saw the photo of the mum and the daughter and the first thing I thought of was, 'Oh, my God, she's a redhead too.' How can that be possible?"
"[It] shouldn't happen once. It certainly shouldn't happen twice."

A preliminary investigation by the Australian Transport Safety Bureau has found the plane crashed just over a minute after take-off and hit the ground almost vertically.
'CASA needs to get off its butt'

[Image: 8723790-3x2-700x467.jpg] Photo: Jacinda and Julie Twigg died when their Angel Flight crashed near Horsham in 2011. (ABC News)

Angel Flight is a much loved service for regional communities and last year organised more than 3,000 flights for free to city medical appointments.

But it is not an aviation organisation which means journeys are taken as private flights.
The charity merely organises the trips by connecting patients with pilots who volunteer their time and their planes. Different safety standards apply when compared with commercial passenger flights.

Mr Twigg said the charity flight sector needed to be regulated.

"Angel Flight, it's a fantastic organisation, don't get me wrong, it is the best organisation and they do so much for so many people," he said.

"But how can they not be responsible for this?

Quote:"CASA (the Civil Aviation Safety Authority) needs to seriously get off its butt and do something. There has to be stricter guidelines.

"Angel Flight cannot just sign someone up just because they put their hand up and they've got an aeroplane and they're prepared to pay the fuel and volunteer their time; they have to be scrutineered."

Angel Flight declined an interview but said responsibility for its volunteer pilots rested with CASA.

Angel Flight chief executive officer Marjorie Pagani stated the charity, in facilitating private flights by volunteers, "relies wholly upon CASA's licensing, checking and training role, and the authorisations it issues to pilots".

In 2014 CASA tried to change the way charity flights operate. It proposed they become more directly responsible for pilots, their training and proficiency.

CASA spokesman Peter Gibson said the proposal was shelved in the face of opposition, including from Angel Flight, which said the changes would be too costly.

"We had in excess of 60-odd submissions to the discussion and overwhelmingly they were against any change," he told 7.30.

But he concedes the latest accident has forced a rethink.

"We don't have the accident investigation report in front of us, that has collected all the data from that accident, done the analysis, looked at all the causal factors," he said.

"When we've all got that, if someone can look at that and say, 'CASA you're at fault', then OK, that'll be a fair discussion to have."

'I got $40,000. That's all my wife and daughter were worth'

[Image: 8723798-3x2-700x467.jpg] Photo: Len Twigg (centre), with his other children Jess (left), and Michael Twigg (right). (ABC News: Angelique Donnellan)

Mr Twigg pursued compensation over his wife and daughter's deaths but said the legal battle caused him more trauma.

As the flight was classed as a private journey, the only claim Mr Twigg could pursue was through the pilot's insurer.

"The insurance policy was worded that if you survived the accident you had a claim, if you were struck by a piece of the aeroplane at the accident site you had a claim, but as a third party there was nothing," he said.

Quote:"In the end I got $40,000. That's all my wife and daughter were worth."

He offered this advice to the family left devastated by the latest Angel Flight crash.
"First thing to do, get in touch with a lawyer and caveat everything of the pilots, everything he owns, so it can't be sold," he said.

"If someone had said that to me I would have said, 'don't be stupid, why would I want to do that?'

"Do it. You can't not think of yourself, you have to think of you, your family, your kids and the future."


MTF...P2 Cool
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A Bilious Confection.

It is not very often that an urge to defend CASA surfaces; quite rare in fact, novel even, however. The story above, from the ABC smacks of the gutter press and unfairly criticises CASA. Gods know, there is plenty of ammunition, targets and scope for pot shots at CASA but I fail, utterly, to see what CASA could have done more to prevent either accident.

VFR into IMC, engine failures, carburettor ice, loud cloud and high ground and the rest of the long list of potential killers and a pilots response to same are totally and completely, beyond, their control.  The standards CASA set for the various grades of pilot qualification are within the boundaries of international standards, the medical condition set for pilots are definitely wrong but they err on the side of caution, the maintenance of aircraft and the requirements for flight all reflect the same cautious approach. In short; CASA have made rules which are designed to prevent, as far as possible, any accident or incident. These rules govern all aircraft operations, Angel Flight and their volunteer pilots included.  

The AF pilots operate under Private Pilot Licence regime; the Australian standard is comparable to the rest of the worlds. In my experience, our PPL holders fly for the sake of it, they enjoy flying and have enthusiasm for learning more and gathering experience. Compare the PPL to motor vehicle licences. Not everyone needs to hold a heavy vehicle licence and drive for a living but almost every adult has a driving licence; this does not mean they are incapable of driving a big rig – just simply means they have no need to. Same as PPL, nothing to say they could not fly a Jumbo, given opportunity and training.

Taking a slap at CASA, the quality of our PPL’s, Angel Flight or even the system on either accident is unreasonable, especially so when the cause of the accident has not been determined.

I will however take a shot at the erstwhile Mr Twigg – if he feels that he is due more compensation then he is free to argue his case in the courts. No easy task I’ll grant you, but that is the system – Karen Casey challenged it and proved, categorically just how pathetic and venal the compensation system for victims of air accident is. But attacking CASA, Angel Flight or the pilots in this manner is not the way to acquire the funds or support Twigg seems to feel he is entitled to. Emotive appeals of this nature, through the media for more money leave me stone cold. Others seek to prevent accidents reoccurring, others seek to define the reasons  for accident, many grieve, many are left behind to wonder. But none that I know of have turned an interview into a ‘poor me – give me more money’ opportunity; yet they all suffer. From Lockhart to Canley Vale; not one single poor soul who has lost a loved one has made such a naked appeal. The system is flawed, we all know that, changing it a long, weary battle; one may either help or get off the paddock – but whining from the side-lines – is for spectators who live vicariously through the efforts of others, then go home.

Toot - toot.
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"A Bilious Confection."

"K" I wholeheartedly agree. The person winging about his lack of compensation loses sight of why his loved ones were on an Angel Flight in the first place.
A little trawl though Google reveals that Angel Flight and its associates in the USA is a huge organisation completing many more missions per year than Australia could dream of, all under the same formula.

The difference I note is that almost 80% of US private pilots hold instrument ratings, compared with about 20% in Australia, now why would this be??

Does holding an instrument qualification go a long way to mitigating a lot of these VFR into IFR accidents?

The lack of instrument qualification in Australia wouldn't be because of our inane regulations and ridiculous "recency" requirements which make it so expensive to obtain that qualification and maintain it that many of our PPL brethren simply forgo that skill as too onerous and costly? We do, after all, have the most benign weather in the world so why bother?

Tens of Thousands of Angel Flight missions completed in the USA, one accident that I can find, against Australia two.

But hang on Australia is the safest country in the world isn't it? or is it just the most expensive? you choose.

The sad thing is this sort of emotional clap trap, sensationally promoted by the ABC could so easily provoke a knee jerk reaction from our dumb ass regulator and the whole concept of Angel Flight regulated out of existence.

If that was to occur it would be interesting to see the Stats on the number of road kill caused, or the number of people
who's health and wellbeing was compromised by the inability to attend timely access to specialist treatment.

Angel Flight is a true Charity, unlike those corporations masquerading as charities that snorkel up vast amounts of taxpayer dollars and bid for commercial contracts with the advantage over commercial operators of paying no tax, not even GST. It would be very sad to see Care Flight become commercialised.
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Full report here, and watch the video of the story..

Quote:Pilot and trainee fighting for life after light plane crash in Melbourne

A pilot and learner pilot are in a critical condition after the light plane they were flying crashed during a training session in Melbourne.

Crews were called to Pound Road in Clyde North just after 10.30am after witnesses reported seeing smoke come from the plane.

Witnesses said it appeared the pilot was looking for a place to land, before signalling a mayday call and crashing into a paddock.

Firefighters had to cut the pair out of the wreckage, with one of the men, aged in his 20s, trapped for hours. He was eventually freed, suffering serious neck, chest and back injuries, and was flown to The Alfred Hospital.

The other man was airlifted to the Royal Melbourne Hospital in a critical condition.

Both men remain in a critical condition this evening.

The Bristol [sic] single-engine aircraft was operated out of Moorabbin by Learn to Fly Melbourne.

One thing I noted from the video was "their full report into what caused the crash could take six months"....but I guess we're talking RA-Aus, and not the ATSB, given the ATSB will only get involved if there are fatalities.

EDIT: Sadly, the young (19 yo) student pilot passed away yesterday afternoon.
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....and this..

Quote:Two Qantas flights return to Sydney after engineering issues

TWO international Qantas flights have been forced to turn back to Sydney due to “engineering issues”.
Reports suggest the Qantas flight A380 QF7 was dumping fuel off the coast.
It departed Sydney for Dallas/Fort worth about 1.40pm.
There are also reports Qantas flight QF63, from Sydney to Johannesburg, has also returned to Sydney.
The QF63 flight landed safely back at the gate at Sydney just before 3.30pm and the QF7 flight was dumping fuel for about 35 minutes. The QF7 flight was circling out in the Tasman Sea east of Wollongong but has now landed at Sydney airport.
Footage of the Qantas jet dumping fuel above Sydney was sent to news.com.au.

The QF63 flight had a crack in the windshield. QF63 passenger Jackson Reynolds said on Twitter there was an issue with the heating mechanism, which caused the crack.
A Qantas customers are also complaining on Twitter about another flight, QF23, which maintenance crews have been fixing for five hours. The issue with that aircraft is unknown.
Qantas said in a statement flight QF7 was also suffering from a mechanical issue.

“The flaps on the aircraft (which are attached to the wing) are unable to retract which means the aircraft can’t fly efficiently," the statement said.
“As the Dallas flight is our longest on the network, the captain made the decision to return to Sydney.
“The aircraft – an Airbus A380 – is expected to land at around 4pm Sydney time where it will be inspected by engineers.
“A second flight, Qantas flight QF63 from Johannesburg to Sydney also needed to return to Sydney due to an engineering issue.
“This aircraft has landed safely. It is a Boeing 747-400 and has an unrelated issue to the QF7.
“Our operational teams are working through accommodating passengers or offering them transport home before replacement services are organised.”

The latest incident comes after a Qantas flight was forced to land in June after it was dumping fuel at sea.
A Melbourne woman on the Los Angeles-bound flight QF93, which diverted to Sydney said the crew made the decision to turn around.
Jessica McCallum, 29, praised Qantas crew for their handling of the situation, after an emergency light came on in the cockpit of the A380 about an hour into the flight.
“A staff member came over toward our row and asked the people in front if they would mind if they had a look at the engine outside the window,” she told news.com.au while still sitting in her seat on the tarmac at Sydney Airport.
“He then rushed off and we didn’t hear anything for a while.
“We were then told about the oil leak affecting the second engine on the left side.
“We were told we would divert to Sydney and land in 25 minutes.
“We were circling around for ages until the pilot could get the centre of gravity of the plane level just so we could land safely.”
In December 2014 a Qantas flight made an emergency landing in Perth after the plane’s air conditioning failed.
It was put into an emergency descent while travelling at some 39,000 feet, eventually levelling out at about 10,000 feet, in order to maintain internal air pressure.
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Angel Flight oversight to be reviewed - Angel

By Meredith Booth via the Oz:

Quote:
Quote:[Image: images?q=tbn:ANd9GcS5WL0nDdi1OX8Jf2HOsh5...6lTARtktlQ]


CASA to re-examine charity flight standard

The Australian 8h ago

Two fatal Angel Flights in six years have prompted Australia’s civil aviation safety regulator to re-examine standards for community service flight providers.

The review was prompted by the June 28 crash of an Angel Flight near Mount Gambier airport that killed private pilot Grant Gilbert, 78 and his passengers Emily Redding, 16, and her mother Tracy Redding, 43 who were on their way to a medical appointment in Adelaide.

It was the second doomed Angel Flight, after experienced volunteer pilot Don Kernot and passengers Julie and Jacinda Twigg, died in August 2011 when their plane crashed in country Victoria on a return flight from Melbourne to Nhill.

Jacinda, 15, was being treated for juvenile arthritis in Melbourne and was returning to her home near Nhill, when the plane came down in poor weather.

Angel Flight Australia is a charity that co-ordinates non-emergency flights to help rural Australians to access city medical services, providing almost 22,000 flights since 2003.

Prompted by the 2011 crash, the Civil Aviation Safety Authority toughened regulations for the sector in 2014, saying the status quo, where any aircraft could be used by any privately licensed pilot, was not “sound safety regulation”. Although it pushed for the charity to self-regulate — including overseeing pilot training, regular pilot checks and aircraft approvals — strong resistance from Angel Flight and its regional supporters prompted any proposed changes to be shelved.

CASA spokesman Peter Gibson said the discussion was now being revisited. “CASA is looking at the safety issues relating to community service flights in the wake of the tragic accident at Mount Gambier,” he said. “However, given the (Air Transport Safety Bureau’s) full analysis will not be available for some months, it is too early to comment on the accident itself or any factors that may have caused the accident.

“As a prudent regulator, CASA always reviews safety issues following serious accidents.”

Angel Flight chief executive Marjorie Pagani said the charity already sought stronger-than-­required CASA standards for its volunteer pilots, including at least 250 hours in command experience. Any changes to regulations on community service flights was the responsibility of CASA.

“We’re happy to co-operate with CASA and the Australian Transport Safety Bureau,” Ms ­Pagani said. “We have 3200 registered pilots; five to six times more than CASA requires for private pilots in a private flight, all documents are checked including current insurance and $10m public liability. We cant do anything but rely on CASA’s standards.’’

The Nhill pilot, Mr Kernot, had 6000 hours in command and Mr Gilbert had “well in excess” of 250 hours.

Ms Pagani said the Mr Gambier crash had not damaged Angel Flight’s reputation. “The support that we had from people in the community, from the passengers from pilots has been nothing short of amazing. The general tenor is this is a tragedy, but please don’t stop,’’ she said.

ATSB’s full report on the Mount Gambier crash is expected by the middle of next year.
MTF...P2 Cool
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Worth a read.
"Generating Revenue from Commercial Development On or Adjacent to Airports"
https://www.nap.edu/catalog/24863/genera...o-airports

https://www.nap.edu/download/24863?utm_s...1cbc5ebe93
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ATSB release Jetstar tail strike incident report - Rolleyes

Via the ATSB: AO-2016-046

Quote:What happened

On 11 May 2016, an Airbus A320-232, registered VH-VGF (VGF) and operated by Jetstar Airways Pty Ltd was taking off on runway 27 at Melbourne Airport, Victoria. The flight crew consisted of a training captain in the left seat, a cadet pilot in the right seat and a safety pilot, who was also the first officer, in the jump-seat. This was the cadet pilot’s first takeoff as pilot flying. During rotation, the tail of the aircraft contacted the runway surface.

After takeoff, the cadet pilot realised that the pitch rate during rotation was higher than normal and discussed this with the captain. During the climb, the cabin crew discussed hearing an unusual noise during the takeoff rotation with the captain. Due to the higher than normal rotation rate and the noise heard by the cabin crew, the captain elected to stop the climb and return to Melbourne. The first officer swapped seats with the cadet pilot and the aircraft landed uneventfully on runway 27.

What the ATSB found

The ATSB found that during rotation, the cadet pilot applied a larger than normal sidestick pitch input resulting in a higher than normal pitch rate. The tail of the aircraft contacted the runway surface resulting in damage to the auxiliary power unit (APU) diverter and APU drain mast. While airborne, the crew did not specifically advise air traffic control (ATC) of the possibility that a tail strike had occurred during takeoff.

What's been done as a result

The cadet pilot undertook additional training and assessment before returning to flight duties. Soon after the event, the operator circulated a newsletter to their A320 flight crew highlighting the need to inform ATC of a suspected tail strike or any potential failure resulting in damage/debris.

Safety message

Good communication from the cabin crew alerted the flight crew that a tail strike may have occurred. The climb was stopped and a timely decision to return to Melbourne was taken which minimised the potential risk from damage caused by a tail strike.
It is important to notify ATC of a possible tail strike as soon as operationally suitable. When a potential tail strike has been reported, ATC restricts operations on the affected runway and arranges that a runway inspection is carried out to identify any runway damage or aircraft debris
& from News.com.au:
Quote:Jetstar plane tail hits runway on cadet pilot’s first takeoff

A JETSTAR flight carrying 134 people from Melbourne to Hobart was forced to turn around after the cadet’s first takeoff went horribly wrong.
[Image: lauren-mcmah.png]
Lauren McMah

September 4, 2017 2:49pm
[Image: dfcd52442d8f526f217fc594293bf11e]
A Jetstar flight from Melbourne to Hobart was forced to turn around after the plane’s tail struck the runway. (File image). Picture: Brad Hunter

A JETSTAR flight with 134 people on board had to turn back to Melbourne after the plane’s tail hit the runway during the learner pilot’s first takeoff.

The Hobart-bound A320 took off from Melbourne Airport on May 11 last year but was forced to return to the runway after the tail strike and when cabin crew heard unusual noises during the plane’s climb, the Australian Transport Safety Bureau (ATSB) said in a report handed down today.

The bureau found good communication among the cabin crew and flight crew meant the flight could return quickly and without risk of damage.

But the flight crew did not tell air traffic control about the tail strike as it should have, the report said.

In its investigation into the incident, the ATSB found the 2.49pm flight took off from runway 27 with a cadet pilot, a training captain and safety pilot in the cockpit.

[Image: 7e120f5225610dbcc0e96a9d6894576c]
There was some damage to the tail of the A320. Picture: Australian Transport Safety Bureau

The cadet pilot had a commercial pilot license and had completed all Civil Aviation Safety Authority training to be qualified to fly an A320. It was their first takeoff as pilot flying.

While the plane was climbing, the cadet pilot and the captain discussed how the pitch rate was higher than normal. This high pitch rate resulted in a high rotation rate during takeoff, which caused the aircraft’s tail to hit the runway, the ATSB said.

“Later, during the climb, the cabin crew alerted the captain to unusual noises during rotation,” the report said.

“As a result, the captain elected to stop the climb and return to Melbourne. The first officer also swapped seats with the cadet pilot.”

The plane landed without incident at 3.23pm and some damage consistent with a tail strike was found.

The cadet pilot undertook additional training and assessment before returning to flight duties.

[Image: d1914b6388964a269785b319ddca64e8]
Damage to aircraft tail section (circled). Picture: Australian Transport Safety Bureau

ATSB said while the plane’s crew handled the situation well, the potential tail strike “was not adequately communicated to Melbourne air traffic control”.

“This delayed checking the runway for aircraft debris,” the bureau said.

In a statement to news.com.au, a Jetstar spokesman said: “The experienced captain and trainer pilot handled this extremely well and with the help of cabin crew ensured the aircraft returned to Melbourne Airport without further incident.

“The pilot involved was taken off flying duties while he underwent additional simulator training and assessments and after successfully passing this training returned to flying and has operated since without further incident.

“There was no structural damage to the aircraft and it returned to service shortly after.
“We use incidents to further improve the safety of our operation and soon after the event, we reminded our pilots of the importance of alerting air traffic control of a potential tail strike.”


MTF...P2 Cool
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There are far too many tail strike incidents happening regularly all over the world, some serious. Something is fundamentally wrong, deep down, which needs to be identified, and fixed.

In the mean time, perhaps we should be putting Tiger Moth skids back on jets, with a sensor, to alert the crew when they have been used, along with an automated immediate acars message with a special code, which the ground network immediately decodes, and flashes it up in red on the airline's maintenance monitoring system. Moreover, the delay (with 90 second runway operations these days) in advising ATC, and indeed possibly not advising them at all, could result in catastrophy one day, if there is debris.

So, the ACARS ground processing system should simultaneously direct the unique (to be assigned) tailstrike message to the control tower (which would obviously need to be "plugged into the system") so that the safety of following aircraft, either landing or taking off, is not compromised, by possible unknown debris. An even better idea, would be to build it into the Mode S message stream as well.
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Sounds de jour. - Groan, ‘thunk’ (report hits bin).

Radical thoughts there “V”. Probably good solid sense and ‘do-able’ but whenever I read that sort of suggestion the ‘history’ channel lights up; the episode that immediately comes to mind is one from back in the earlies, when ‘commercial’ air transport was developing in the USA. There was a helluva battle between the pilots and the operators to get ‘nav lights’ fitted; it got serious, took a long while and (from memory) took government interference to make it happen. The battle lines between what aircrew believe they need and what management is prepared to pay for is an ancient game. Take the fatigue rules for example; or the OTP pressures, fuel uplift pressures etc.  A long winded way of saying good idea on its way to the archives.

Tail strikes do happen, there are some very good analysis available as to ‘why’. The offering from ‘Sky Library’ is technical enough for general use and provides a sound base for avoidance training; there are better, more detailed, technical volumes available, but for one to understand ‘what’ is involved at a base level the SL version is a good as any. Pity the ATSB investigators have not read it.  

What we have from the ATSB is a highly ‘judgemental’ report, singing the praises of the cabin and flight deck crew, particularly their ‘communications’ skills. Which is a load of subjective, feel-good bollocks. What we don’t have from ATSB is detailed analysis of ‘why’ the strike occurred:-

“The ATSB found that during rotation, the cadet pilot applied a larger than normal side-stick pitch input resulting in a higher than normal pitch rate.”

No! - Really? - Hoodathunkit.  A ‘cadet’ over pitching the airframe. I could swallow a newly minted, but fully qualified FO banging the airframe about – with some of the ‘standard’ reasons for that occurring explained, it becomes acceptable. But WTD is a ‘cadet’ doing out of the sim centre operating a live revenue flight?  It the cadet’ was qualified then why not call it the FO (even under supervision). Why could the PIC not put a steadying hand on the side-stick to prevent the over pitch – we’ve all done it – the nose rears up and the steadying hand acting as a buffer to prevent enthusiasm turning to disaster. You would not consider doing this with a qualified, clear to line operations FO, but with a ‘cadet’ – you’d be watching like a hawk on a mouse. (Oh, it was an Airbus, then things are different; no matter). Unless of course, the use of the word ‘cadet’ is misleading in this instance; even so, ATSB should have qualified the definition, to avoid confusion and perhaps mentioned the Airbus control system.  

The ‘safety message’ is valueless, vague, judgemental and avoids the real issues; or, as TOM would say – ‘ducking useless, of neither practical nor intrinsic value, except to the spin doctors telling the public just how safe they all are’.

Toot – toot.
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Yet another ATSB PC'd report - Dodgy

The ATSB report - Incorrect configuration involving ATR - Gie Avions De Transport Régional ATR72, VH-FVL - & via Oz Aviation:

Quote:ATSB highlights crew workload in Virgin Australia ATR go-around report
September 6, 2017 by australianaviation.com.au
 
[Image: ATR-72-VIRGIN-AUSTRALIA-BNE-SEP11-RF-IMG_0399.jpg]A file image of a Virgin Australia ATR 72 turboprop at Brisbane Airport. (Rob Finlayson)

A Virgin Australia ATR 72 operating a flight from Moranbah to Brisbane had to conduct a go-around after an incorrect flap settings was selected on approach, the Australian Transport Safety Board (ATSB) says.

The incident occurred on April 2 2017 when ATR 72-500 VH-FVL, with 38 passengers and four crew onboard, was turning onto final approach for Brisbane Airport’s Runway 19.

At that time, the captain, who was the pilot flying, directed the first officer, who was the pilot monitoring, to select flap 30, set the airspeed indicator bug to the approach speed (VAPP) and start the before landing checklist.

However, the ATSB report said the flightcrew noticed during final approach the aircraft was “not performing as expected”, with its airspeed higher than during a normal approach.

“The captain had to keep adjusting the aircraft attitude and engine torque setting to control the speed,” the ATSB said.

Later, as the aircraft descended to 173ft, the enhanced ground proximity warning system activated with the alert, “TOO LOW FLAP”.

The captain then immediately conducted a missed approach and during the subsequent climb, called “flap 15, check power” and the first officer responded accordingly.

The aircraft then conducted the same approach to Runway 19 and after landing the captain decided to stand the crew down and not conduct the next two sectors.

Flight data showed the flaps were incorrectly set for conducting a normal landing.

“During the approach, the first officer moved the flap lever up from flap 15 to flap 0, instead of from flap 15 to flap 30 as intended. This resulted in an unstable approach,” the ATSB report said.

“The crew did not identify the incorrect flap setting until the ground proximity warning system alerted them to an incorrect configuration, likely due to workload.”

The ATSB report said the first time the captain became aware of that the flap was set to 0 degrees was during a review of the flight data animation conducted by the airline.

“Since the incorrect flap setting was not detected by the crew on approach, had they managed to slow the aircraft to the VAPP of 104 knots for flap 30, they would have been 2 knots below the stall speed for the actual flap setting (106 knots),” the ATSB said.

Meanwhile, the ATSB report noted the workload of the crew increased during the approach, when there was a combination of turning onto he final approach path, conducting a visual approach, managing radio calls with air traffic control and responding to the unexpected aircraft performance.

“Flap settings are generally confirmed through the completion of the before landing checklist, whereby the flap lever and indicator must be visually checked,” the ATSB report said.

“However, in this case, this part of the checklist happened during a high workload period, and it was subsequently rushed. This checklist item may have been missed.

“This investigation highlights the potential impact crew workload has on flight operations as it can lead to adding, shedding, or rescheduling actions. Handling approaches to land continues to be a safety priority for the ATSB.”

However back to the Jetstar tailstrike incident and the Oz Aviation coverage of this would seem to confirm that it was a cadet who was the PF of this flight:

Quote:ATSB releases Jetstar tail strike report
September 5, 2017 By australianaviation.com.au 3 Comments

The Australian Transport Safety Bureau (ATSB) has released its report into a tail strike incident involving a Jetstar Airbus A320 taking off from …

 Although a little ambiguous, it could be interpreted that the cadet pilot was in fact conducting the flight as a CTL First Officer:

Quote:..It was the cadet pilot’s first flight as the pilot flying. Alongside him in the flightdeck was a training captain in the left seat and a safety pilot in the jump seat...
  
P9: ..Why could the PIC not put a steadying hand on the side-stick to prevent the over pitch – we’ve all done it – the nose rears up and the steadying hand acting as a buffer to prevent enthusiasm turning to disaster. You would not consider doing this with a qualified, clear to line operations FO, but with a ‘cadet’ – you’d be watching like a hawk on a mouse. (Oh, it was an Airbus, then things are different; no matter)...

Absolutely spot on "K" - Shirley the CASA approved Jetstar T&C system for 'cadets' has a more robust simulator CTL to facilitate the line training fallibilities and limitations of the A320 vs the Boeing equivalent... Huh  

MTF...P2  Cool
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(09-06-2017, 07:41 PM)Peetwo Wrote: However back to the Jetstar tailstrike incident and the Oz Aviation coverage of this would seem to confirm that it was a cadet who was the PF of this flight:

Quote:ATSB releases Jetstar tail strike report
September 5, 2017 By australianaviation.com.au 3 Comments

The Australian Transport Safety Bureau (ATSB) has released its report into a tail strike incident involving a Jetstar Airbus A320 taking off from …

 Although a little ambiguous, it could be interpreted that the cadet pilot was in fact conducting the flight as a CTL First Officer:

Quote:..It was the cadet pilot’s first flight as the pilot flying. Alongside him in the flightdeck was a training captain in the left seat and a safety pilot in the jump seat...
  
P9: ..Why could the PIC not put a steadying hand on the side-stick to prevent the over pitch – we’ve all done it – the nose rears up and the steadying hand acting as a buffer to prevent enthusiasm turning to disaster. You would not consider doing this with a qualified, clear to line operations FO, but with a ‘cadet’ – you’d be watching like a hawk on a mouse. (Oh, it was an Airbus, then things are different; no matter)...

Absolutely spot on "K" - Shirley the CASA approved Jetstar T&C system for 'cadets' has a more robust simulator CTL to facilitate the line training fallibilities and limitations of the A320 vs the Boeing equivalent... Huh  

Follow up - Rolleyes

Extracts from the ATSB report:

Quote:..The flight was scheduled as a training flight with the cadet pilot conducting his fifth sector of line training and the first sector of the current shift. There was also an FO in the jump seat acting as a safety pilot. The four previous sectors had been flown with the cadet pilot as pilot monitoring (PM). This was the first flight for the cadet pilot as PF...


&..

Due to the higher than normal rotation rate and the noise heard by the cabin crew, the captain elected to stop the climb and return to Melbourne. The first officer swapped seats with the cadet pilot and the aircraft landed uneventfully on runway 27.


Findings

From the evidence available, the following findings are made with respect to the tail strike during takeoff involving Airbus A320 VH-VGF at Melbourne Airport, Victoria on 11 May 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factor

The cadet pilot applied a larger than normal sidestick pitch input to initiate rotation. This resulted in a high rotation rate during the take-off and the aircraft’s tail contacted the runway.

Other factor

The potential tail strike was not adequately communicated to Melbourne air traffic control. This delayed checking the runway for aircraft debris.

Besides the seemingly glossed over T&C issues mentioned previously, I also question why the ATSB did not probe the safety issue with the Training Captain, apparently in the middle of conducting a Abnormal operation, made a command decision to stand down the cadet pilot and fly the aircraft single pilot until the Safety Officer FO had swapped seats with the cadet??

 Maybe I am missing something?? - But Shirley it would've been more advisable for the cadet to remain in the RH seat and conduct the rest of the flight as PM, a role that he had successfully carried out on five previous sectors... Huh       


MTF...P2 Cool
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Terminology and ‘clutter’.

The use of the term ‘cadet’ muddies the waters a bit and without hard fact we are left making assumptions. But if we look on the ‘bright’ side, lets assume the ‘cadet’ had completed a simulator type rating and all the trimmings; before doing either in the aircraft, we can assume that both take off and landing had been correctly executed to a satisfactory standard. The modern simulators very closely represent the actual aircraft and, in theory at least there is little to no difference that matters. Soon or late the ‘cadet’ must fly the real aircraft – on line. The system using a TC as PIC and a seasoned FO in the jump has proved to be a good one, I assume many ‘cadets’ have been eased into operational flying through the system, quite safely and properly. So let’s not quarrel over the word ‘cadet’, it may be a misleading title, but we have to call ‘em something until they become FO’s proper. I don’t think we can lay any blame at the door of the ‘training’ given or the system used. Which takes us back to the shabby report.

Item 1: let's say the cadet has had a good grounding in the sim and four sectors as PM; so this is not the first rodeo; yet there was a tail strike – why? An independent analysis of what caused the strike would be of benefit to all and sundry.

“The cadet pilot applied a larger than normal side-stick pitch input to initiate rotation. This resulted in a high rotation rate during the take-off and the aircraft’s tail contacted the runway.”

This is cited as a ‘contributing factor’. Bollocks, after the fact result.  “a larger than normal side-stick pitch input to initiate rotation”. What brought that on? IMO it is essential that we understand why the child, despite training, practice, mentoring and monitoring managed such a thing. Under rotation due to caution – OK, I could accept that. Over rotation due to unfamiliarity - in the Sim; I could accept that; but by the time young spotty is conducting a take off, for real, then the reasons for the action need to be examined – if only to fully understand it as a matter for future training. It is no ones fault and I don’t seek to lay blame, however I would like to know exactly what was going on in the ‘cadets’ head at the time, simply to prevent this happening again. An independent assessment by the ATSB could have shed some light on this event and perhaps prompted a minor modification to the training system – one which may have  been overlooked - who knows. Statistically, this event would be a tiny dot; betcha there are 100 good, clean, first real take offs made by ‘cadets’ to this one. Even so – if it can happen once, it can happen again and early prevention is better than a late cure. No doubt the airline T&C system has already taken pro-active steps; but without the ATSB being involved in any meaningful way – again.

The changing of seats puzzles me; the PIC effectively operating single pilot for the short period. Now if the ‘cadet’ was full bottle why bother? It was only a tail strike, and return – ops normal - not a full on ‘emergency’. What if there had been fire, smoke or any of the other gremlins which make a time critical ‘emergency’. What then? Low level, emergency, turbulence, two out of three pilots unstrapped, falling over each other trying to reposition while the whistles and bells are demanding multi crew attention - now - now. Nah, not funny. If the rules say that the FO must be qualified to be ‘crew’ during abnormal or emergency operations; then the crew operating must be capable of dealing. You can’t have people leaping about the cockpit when the do-doo hits the windmill. ATSB fail, yet again, to offer advice or analysis on a potential cluster of ducks. Once again we must rely solely on the good sense of the operating company T&C system to take a long hard look at the case, draw their own conclusions and fix it. This does not excuse the ATSB from having a meaningful, independent input to the incident.

Aye well; something nothing – that ‘cadet’ is unlikely to repeat the error; the T&C will sort it out and the ATSB will continue providing reports with less meaning than the Sunday papers mention of it. It’s Hi-viz, hot air and no responsibility for all in the political world of the ATSB.

Toot toot.
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Story here..
Quote:ROSSAIR TO FLY AGAIN AFTER SA CRASH

A South Australian based charter airline, grounded since a fatal crash earlier this year, will fly again.
Rossair on Friday announced a joint venture with Victorian based AusJet.
The company's CEO Warren Puvanendren said the partnership would allow the airline to resume services for SA's mining, energy and tourism industries.
"After a challenging few months, the combination of both groups' fleet and experienced staff will allow us to commence servicing our clients immediately," Mr Puvanendren said.
"We are proud of what this opportunity with Ausjet can deliver to the SA charter market."
A Rossair plane on a training exercise crashed in the Riverland in May killing three people, including the company's chief pilot.
An initial report by Australian Transport Safety Bureau found the Cessna Conquest hit the ground nose first soon after take off from the Renmark Airport.
Killed in the crash was chief pilot Martin Scott, 48, fellow pilot Paul Daw, 65, and Civil Aviation Safety Authority inspector Stephen Guerin, 56.
The ATSB is expected to hand down its full report within 12 months.
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Gee Whiz – there’s a ‘fuss’ going on over at UP. Some cadet failed to set the flap for landing; the skipper stood the crew down after a flapless landing. All kinds of bitch slapping and hair pulling going on – except no one has asked the important question.

Why didn’t the PIC ‘look’ and ‘check’ that the flaps were indeed where they should be?  Had a 1000 feet to do it in; just a quick glance; make certain all is as it should be.

Where is the SOP which says ‘cross check’  - ALWAYS. Routine - in my poor old wooden head - check speed – call for flap – note running and check set – “Flap 30?” – Confirmed. Poor old cadet gets a UP flogging though; for strange PIC behaviour and piss poor SOP.
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Reported on back up here Ol'Tom:

Quote:Yet another ATSB PC'd report - [Image: dodgy.gif]

The ATSB report - Incorrect configuration involving ATR - Gie Avions De Transport Régional ATR72, VH-FVL - & via Oz Aviation:

Quote: Wrote:ATSB highlights crew workload in Virgin Australia ATR go-around report
September 6, 2017 by australianaviation.com.au
 
[Image: ATR-72-VIRGIN-AUSTRALIA-BNE-SEP11-RF-IMG_0399.jpg]

A file image of a Virgin Australia ATR 72 turboprop at Brisbane Airport. (Rob Finlayson)
 
Also covered by PT where some of the comments are a little bit more balanced than off the UP:
Quote:[Image: VA-ATR-wikipedia-e1504658769218.jpg]
Botched Virgin turboprop landing attempt sees captain stand himself down

Ben Sandilands Sep 6, 2017 6 Comments
Safety investigator silent on how Virgin Australia responded to pilot confusing flaps zero with flaps 30 in botched landing approach


On April 2 this year a Virgin Australia ATR turboprop was flown at the wrong speed and flap setting toward an intended landing at Brisbane Airport with 38  passengers as well as two cabin crew and two pilots on board before the captain broke off the approach after an audible warning from its enhanced ground proximity warning system.

The high wing regional airliner was less than 172 feet off the ground when the synthetic voice called TOO LOW FLAP and the captain, who was flying the approach, initiated a go-around, climbing away from the airport and bringing the flights which had started at Moranbah back for a properly configured landing.

According to the [b]ATSB investigation[/b] into this serious incident, published today, the captain was so concerned at the events of that initial landing attempt that he then decided to stand himself and the rest of the crew down and not operate the next two intended regional flight sectors.

As the ATSB reports, it turned out that when the captain had called for the first officer to set the aircraft’s flaps to 30 degrees the junior pilot set them to the other end of the scale, at zero degrees.

The ATSB points out that had this setting been retained, the aircraft would have been moving at just under stalling speed, that is, no longer technically flying, when it made contact with the ground.

The ATSB doesn’t elaborate on the perils of such a situation, but they should be self evident. A stalled airliner discharging its kinetic energy without control on a runway at night. What could possibly go wrong?

There is no detailed explanation as to why the captain cancelled his and his crews participation in the intended next two flight sectors for this duty period.  Yet the ATSB reveals that the captain didn’t learn that the first officer had set the flaps to zero at the wrong moment, until the airline showed him a post flight animation, some time after the serious incident occurred.

This report is very thorough on the technical side as required by such an investigation. But it is silent on what actions Virgin Australia may have taken subsequently to prevent such incidents exposing their employees and their customers to the dangers or risks they pose.

In compiling this report on the ATSB investigation no media response has been sought from the airline. All that counts in these investigations is what the ATSB says it found, not statements from carriers that unfailingly state that safety is their Number One priority.

It might be this or any carrier’s number one priority, and it can be argued that it is in fact an absolute requirement of their holding an air operator certificate for the aircraft concerned and the procedures the company undertakes to enact.  These responsibilities are mandatory for Australian airlines and the personal responsibility of each and every one of their board members.  They aren’t optional, and they don’t involve the exercise of choice to make them ‘the priority’. They are compulsory.

In this case, if its accepted that safety is the number one priority of the carrier, then that priority wasn’t successfully applied.


MTF...P2 Tongue
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(08-18-2017, 08:36 AM)Peetwo Wrote: Angel Flight oversight to be reviewed - Angel

By Meredith Booth via the Oz:

Quote:
Quote:[Image: images?q=tbn:ANd9GcS5WL0nDdi1OX8Jf2HOsh5...6lTARtktlQ]


CASA to re-examine charity flight standard

The Australian 8h ago

Two fatal Angel Flights in six years have prompted Australia’s civil aviation safety regulator to re-examine standards for community service flight providers.

The review was prompted by the June 28 crash of an Angel Flight near Mount Gambier airport that killed private pilot Grant Gilbert, 78 and his passengers Emily Redding, 16, and her mother Tracy Redding, 43 who were on their way to a medical appointment in Adelaide.

It was the second doomed Angel Flight, after experienced volunteer pilot Don Kernot and passengers Julie and Jacinda Twigg, died in August 2011 when their plane crashed in country Victoria on a return flight from Melbourne to Nhill.

Jacinda, 15, was being treated for juvenile arthritis in Melbourne and was returning to her home near Nhill, when the plane came down in poor weather.

Angel Flight Australia is a charity that co-ordinates non-emergency flights to help rural Australians to access city medical services, providing almost 22,000 flights since 2003.

Prompted by the 2011 crash, the Civil Aviation Safety Authority toughened regulations for the sector in 2014, saying the status quo, where any aircraft could be used by any privately licensed pilot, was not “sound safety regulation”. Although it pushed for the charity to self-regulate — including overseeing pilot training, regular pilot checks and aircraft approvals — strong resistance from Angel Flight and its regional supporters prompted any proposed changes to be shelved.

CASA spokesman Peter Gibson said the discussion was now being revisited. “CASA is looking at the safety issues relating to community service flights in the wake of the tragic accident at Mount Gambier,” he said. “However, given the (Air Transport Safety Bureau’s) full analysis will not be available for some months, it is too early to comment on the accident itself or any factors that may have caused the accident.

“As a prudent regulator, CASA always reviews safety issues following serious accidents.”

Angel Flight chief executive Marjorie Pagani said the charity already sought stronger-than-­required CASA standards for its volunteer pilots, including at least 250 hours in command experience. Any changes to regulations on community service flights was the responsibility of CASA.

“We’re happy to co-operate with CASA and the Australian Transport Safety Bureau,” Ms ­Pagani said. “We have 3200 registered pilots; five to six times more than CASA requires for private pilots in a private flight, all documents are checked including current insurance and $10m public liability. We cant do anything but rely on CASA’s standards.’’

The Nhill pilot, Mr Kernot, had 6000 hours in command and Mr Gilbert had “well in excess” of 250 hours.

Ms Pagani said the Mr Gambier crash had not damaged Angel Flight’s reputation. “The support that we had from people in the community, from the passengers from pilots has been nothing short of amazing. The general tenor is this is a tragedy, but please don’t stop,’’ she said.

ATSB’s full report on the Mount Gambier crash is expected by the middle of next year.

In a follow up to the CASA review of Angel Flight, I note the following addition to the HoR Adjournment debate, courtesy of the member for Farrer the Hon Sussan Ley MP... Rolleyes :

Quote:Air Safety
[Image: 00AMN.jpg] Ms LEY (Farrer) (16:56): I rise to discuss matters concerning aviation safety and to submit to the parliament a view that Australia needs new safety standards for community service flights conducted on a voluntary basis. Many who live in rural and remote Australia, as I do, are familiar with Australia's best known charity medical air service, Angel Flight, operating since 2003, an organisation that coordinates non-emergency flights flown by volunteer pilots to transport country passengers to medical appointments, usually in capital cities.

In the last six years, there have been two fatal flights, the most recent being on 28 June near Mount Gambier, in which the pilot and two passengers were killed. In August 2011 another flight crashed near Nhill in western Victoria, again with no survivors. I will resist commenting on the causes of the accident earlier this year, as its circumstances are subject to an ongoing Aviation Transport Safety Bureau investigation. At the end of 2013, the ATSB released its report into the 2011 accident and found as follows:

… the pilot probably encountered reduced visibility … due to low cloud, rain and diminishing daylight, leading to disorientation, loss of control and impact with terrain.
This was a clear safety message about the risk of such flights made by pilots without high instrument flying proficiency and recent night experience.

In 2014, CASA released a discussion paper in which it sought to toughen regulations for community service flights. The paper argued:

As community service flights become more widely used, the variable pilot qualifications and aircraft certification and maintenance standards become significant potential risk factors.

It canvassed 10 administrative and/or operational options, noting that too heavy a regulatory hand would mean the cost of compliance would effectively rule such flights impossible. At the time there was strong resistance to change from Angel Flight and from regional communities, and the proposed changes were shelved. However, following the latest tragedy, CASA announced that it will re-examine standards for flights like Angel Flight. That is a good thing. As a general aviation pilot, with a commercial licence I earned in 1980 and having had a career as a bush pilot and still flying myself across the big distances of western New South Wales, I am the very last person to wish for additional regulation on pilots, and it gives me no pleasure to call for change within a charitable organisation that has at its heart and soul the volunteering, giving spirit of so many country people. But a passion for flying and a love of helping people are not sufficient without adequate safety standards.

Most people are familiar with charter flights that leave their local regional airports from time to time—small planes that come and go from out-of-the-way places—and they would consider that the Angel Flight used by their family member is covered by the same rules and regulations. I believe they'd be surprised to know that this is not the case. Operators of charter flights must have an air operators certificate and conform to a far higher standard than regular private flights. Much of this standard is frustratingly bureaucratic, but at its heart is the critical imperative of aviation safety. In the case of a charity flight, the relationship that would exist in a private flight doesn't exist. The members of the public are unsuspecting. There is an element of vulnerability about their circumstances, particularly when children are involved. This may introduce a degree of operational pressure. The level of competency of pilots flying the trips may be as high as or higher than that of those who fly regular public transport routes, or it may be lower than the level of an average pilot.

I have criticised CASA many times over the years, but their 2014 discussion paper should be revisited. Their preferred option—an approved self-administering aviation organisation—would allow this sector to regulate itself. Changes must be made, and I do believe a way forward can be found so that our volunteer pilots can continue to help support country people's access to medical services.

House adjourned at 17:00
 


MTF...P2 Cool
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More tea Vicar?

‘Tis but a ramble M’lud; with your indulgence (or without) I will proceed:-

“Two fatal Angel Flights in six years have prompted Australia’s civil aviation safety regulator to re-examine standards for community service flight providers.”

“As community service flights become more widely used, the variable pilot qualifications and aircraft certification and maintenance standards become significant potential risk factors.”

You can almost hear the barricades being raised, the knives being sharpened and the same old saws being tuned up. This has dragged on for years now and we are no closer to an acceptable – compromise – solution.

There are some good ideas around although if AF don’t sink ‘em, then CASA will. AF will take a position that if the CASA ‘standards’ for PPL are not good enough then – blah, blah. CASA will say they are and then blah, blah. The ‘legal eagles’ do what they do and the party continues.

One of the better solutions, IMO, comes from the AOPA and is worth some thought. I’ll not go into the nitty-gritty for sake of brevity; but it runs something like this. Put together a couple of ‘week-end’ training courses, for AF pilots to attend. Draw CASA into the construction of those courses, to add value and to make it ‘official’. There are a variety of subjects which are of value – Meteorology – understanding and ‘reading’ of actual and forecast conditions. Flight and contingency planning for the expected conditions and time frame. Aircraft performance and fuel planning. Fatigue and delay anticipation; CFIT analysis; Icing. All valuable ‘add on’ to a basic licence. You could add in current  night proficiency and ‘bad weather’ circuits; even forced landings on the practical side. In short, provide the ‘tools’ needed for survival when the going gets tough.  I’d love to include basic ‘instrument proficiency’ to the list; but the deeply entrenched ‘sides’ will not consider compromise of any description. Shame really; only my personal take, but if a pilot has the ‘basics’ then those may be ‘practiced every flight; speed and height control, turns to a heading – etc. to maintain a level of competence in a situation where control could be lost – if the pilot was dopey enough to get into a situation which required the ability. Leaving it there – I can hear the old chain saw engines firing up.

A tailor made course, for AF crews, a record of current experience and a small amount of operational rostering control.  AF offers Bloggs a long day – every chance of a return after dark – night current (Yes) – (No); simple go or no-go decision.

There is a notion to align ‘qualification’ to ‘region’ which is worth (IMHO) a moments thought. Extreme would be a pilot who has flown mostly out of say St George to Roma taking on a flight from Bendigo the Melbourne in the middle of winter on a bad day. There is nothing legally preventing that from happening – however, from a practical point of view…..

I don’t believe CASA want to come down ‘heavy handed’ on a valuable community service; AF certainly don’t want their operations constrained; but, there have been two, high profile, fatal accidents and because it involves ‘sick people’ the topic is ‘emotive’ which makes it fodder for political animals and the media.

Proactive cooperation, collaboration and serious, considered, balanced input from ALL those concerned is needed – well, that and a brave umpire; wonder if Solomon is available? Hate to see the AF wings clipped; but, we can’t have the percentage chances of a fatal accident any higher than they are now. Pity AOPA is on the ministerial nose – there is enough sense being talked there at the moment to be of value to the discussion.

Ramble over- just the stray thoughts and musings of an idle mind.

Toot - toot
Reply
An observation or two and a couple of questions regarding these incidents K.
Why in the US do more than 80% of the private pilot brigade hold instrument ratings but in Australia less than 20% hold that qualification? Wouldn't be that gaining and maintaining that qualification is just too expensive and onerous here compared with there? Would holding that qualification have reduced the likelihood of these events occurring?

I wonder how many "Items" are in the ATR before landing checklist? I know with some of the older transport aircraft checklists designed way back when and probably designed by the manufacturers lawyers with "liability" in mind, tended to contain a myriad of "As required" responses to non critical items which created a forest of trees masking the wood. As an example the Boeing 767 before landing checklist contains only three items as opposed to fourteen in a fairly sophisticated Corporate type.
Our aviation "Experts" simply will not listen to reason as to why, in the modern era,  these checklists should be modified to better emphasise the kill items make the checklists much shorter and less likely to be interrupted by workload.

'K" edit - Choc Frog and Amen.
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The latest ATSB REX final report -  Huh


Via Oz Aviation.. Wink :
Quote:ATSB releases Rex engine failure report
September 18, 2017 by australianaviation.com.au 2 Comments

[Image: Saab-340-Rex-VH-RXS-SYD-AM-2.jpg]A file image of VH-RXS (Andrew McLaughlin)

The Australian Transport Safety Bureau (ATSB) says a lack of lubrication was the most likely cause of an engine failure involving a Regional Express (Rex) Saab 340B on March 23 this year.

The incident occurred shortly after the turboprop VH-RXS took off from Dubbo bound for Sydney carrying 26 passengers and three crew.

When the aircraft was climbing through 4,300ft, the flightcrew “heard several bangs from the right engine accompanied by jolts through the aircraft”, the ATSB final report published on Monday said.

This was accompanied by a burning smell in the flightdeck alongside cockpit master warnings.

The pilots conducted a shutdown of the right hand engine, declared a PAN to air traffic control and requested emergency services at Dubbo Airport.

They then completed standard failure management procedures before the captain conducted a visual approach back to Dubbo Airport, landing on Runway 05.

There were no injuries, while the aircraft suffered minor damage.

The ATSB report said an initial engineering examination found the number four bearing on the right hand engine failed.

“The bearing failure allowed the high pressure compressor to move off-centreline within the engine. This caused further damage and led to complete failure of the engine,” the ATSB said.

“The damage to the failed bearing was consistent with overheating due to a lack of lubrication. At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.”

The ATSB said the engine manufacturer’s engineering examination of the failed engine was not completed at the time its final report into the incident was released.

The Saab 340B is powered by two General Electric CT7-9B turboprop engines.

Meanwhile, the report said comments from the captain indicated emergency procedures and simulator training prepared the flightcrew well for the incident and allowed it to effectively manage the engine failure.

“Faced with an abnormal situation, the training provided to the flightcrew ensured they were able to effectively implement the standard failure procedures, secure the failed engine and return for a safe landing,” the ATSB report said.

“During an emergency, flight crew prioritise the management of the emergency to ensure that the safety of the flight is not compromised. Completing the emergency procedures, along with the coordination of emergency services and communications with supporting agencies may absorb a significant amount of time before the flightcrew are able to provide an update to passengers.”

The two comments are IMO also worth regurgitating:

Quote:Comments

  1. AlanH says

    September 18, 2017 at 8:47 pm

    This, along with the loss of a propeller above Camden. The Saab 340Bs are a terrific aircraft that have served Rex exceptionally well and certainly are a good “fit for purpose” for Rex operations, but they are getting long in the tooth. Perhaps Rex needs to look at updating its fleet sooner rather than later before a catastrophe occurs. ATR 42 perhaps?

  2. Adrian P says

    September 19, 2017 at 10:20 am

    Not sure how it is possible to have a final report when the engine manufacturer’s engineering examination of the failed engine is not completed. If the primary issue is a lubrication failure, need to know why, before another lubrication failure occurs.


Adrian makes an excellent point and I would add that it is normally accepted that a 'serious incident' investigation will inevitably take at least a year to complete and therefore given this incident occurred on 23 March 2017 I have to ask - what the hell is the rush??

For those interested here is the link for the final report: https://www.atsb.gov.au/publications/inv...-2017-034/

P2 comment - This bit under the 'WTD happened' kind of bemused me... Huh

Quote:Figure 1: Regional Express SAAB 340B, registered VH-RXS
[Image: ao2017034_figure-1.png?width=463]
Source: VJ Bhana

After completing the memory items, the flight crew commenced the standard failure management procedures. The flight crew secured the right engine and established that the aircraft was performing satisfactorily. The flight crew declared a PAN[2] to air traffic control and requested emergency services. The flight crew then descended the aircraft to 4,000 ft and identified an area to the south-east of Dubbo which was clear of cloud and other traffic. The first officer manoeuvred the aircraft to this area in order to reduce workload while the flight crew continued the standard failure procedures. The captain identified Dubbo as the most suitable airport for landing. The flight crew reviewed the weather conditions for Dubbo and elected to conduct a visual approach and landing. The flight crew then briefed the cabin crew member on the situation, advised that they were returning to Dubbo and to expect a normal disembarkation.

Maybe it is the disjointed way it is written but the above text gets even more confused when you consider the Captain's comments:
Quote:Captain comments

The captain of the flight provided the following comments:
  • The first officer remained as the pilot flying until they were prepared to make the approach, as this allowed the captain to focus on the engine failure checklist.
  • Emergency procedures and simulator training undertaken by the flight crew was effective. The training prepared the flight crew well for the incident and along with the procedures in place, allowed the flight crew to effectively manage the engine failure.
  • During emergencies, it is important to follow procedures and not rush. This ensures all necessary actions are completed correctly. At each step, take a moment to review the overall situation and aircraft performance to ensure that it is safe to continue.
  • The engine failure checklist instructs the flight crew to consider a restart of the failed engine. At the time of the failure the right engine low oil pressure, over-temperature and chip detector[3] warnings all illuminated. As the warnings indicated that the engine was damaged and not recoverable, the captain elected not to attempt to restart it.
  • There was cloud in the area of the runway 05 area navigation (RNAV)[4] approach, the captain elected to remain clear of cloud and conduct a visual approach. As the runway 05 RNAV approach had quite a high minimum descent altitude, entering cloud may have resulted in a single engine missed approach.
  • After the flight, the captain received reports that passengers were concerned at the length of time taken after the engine failure for the flight crew to update them on the situation.

Maybe it is lost in translation in the butchered ATSB desk top report but the Captain's comments would seem to be attempting to justify why it was that the flight crew elected to conduct a single-engine cloud break procedure in lieu of a much safer runway 05 IAP... Huh


MTF...P2 Cool
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