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1. Recent RA-Aus fatal accident history

Rev. 25 — page content was last updated 1 August 2015

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Dr Rob Lee, the then Director of the Australian Bureau of Air Safety Investigation, wrote in 1998: "Over 40 years of investigation of general aviation accidents, by BASI and its predecessors, clearly shows that while the immediate circumstances of each accident may well be unique, the underlying [human] factors are always drawn from the same disturbingly familiar cluster — pre-flight preparation and planning, decision making, perception, judgement, fuel management and handling skills".

A preliminary study of the factors contributing to fatal general aviation accidents in Australia for the ten years up to 2000 showed that flight planning was a factor in 38% of the accidents, aircraft handling errors in 30% and fuel starvation or exhaustion in 10% and it appears that much the same proportions continued in 2001 to 2010. There is no reason to believe that the sport and recreational aviation experience differs markedly though the likelihood of engine mechanical or electrical failure is higher than in general aviation thus — though engine failure in itself shouldn't cause a serious accident — when combined with faulty judgement and decision making it also figures prominently amongst our causal factors.


1.1 'Lies, damned lies and statistics'

We seem to have heard of more fatal accidents in recent years. Why are these accidents occurring? Are RA-Aus sport and recreational pilots and/or aircraft less safe than they were in the 1990s?
A person believing that fatalities are inevitable in sport and recreational aviation and examining the fatal accident statistics for the five years 2008 through 2012 (an average of 3.6 per annum) might have concluded that the RA-Aus membership — being representative of powered, fixed-wing, sport and recreational aviation — had, perhaps, then been achieving near-reasonable safety results, after taking into account the fading away of the older ultralight types and the continuing introduction of faster, heavier, more complex and less docile aircraft; together with a marked reduction in the average years of experience of the RA-Aus pilot base. The latter is because of the accelerated intake, and training, of new pilot members during the years 2005-2010 — although there was a very high turnover in newer members.

But RA-Aus total voting membership peaked at 10 008 in January 2012 and subsequently experienced a net reduction during 2012-2014. The RA-Aus aircraft register also peaked in early 2012 at 3414 and has reduced to around 3200 in early 2015.

However with 11 fatal accidents in 2013 the statistics increased to average 5.8 p.a. for the four years 2010 through 2013; then there were 6 fatal accidents during 2014 increasing the 4-year average to 6.5 p.a. Compounding this were 9 fatal accidents during the January through July period of 2015; IF there are no further accidents during August to December 2015 those 9 accidents will increase the 4-year (2012 through 2015) average to 7.3 p.a. The worst period since the mid-1980s, but the year still has 5 months to go!

Such cold, bare statistics fail to reflect the family heartache and economic difficulties resulting from fatal accidents and severe injuries – and the distress that ripples out into the wider community. What adds to the distress, for all of us, is the knowledge that so many current and future accidents have been, or will be, assessed as 'pilot error' or 'human error' and the association just seems incapable of doing anything about it!

Generally, shortcomings in knowledge, awareness and task management plus misjudgement and/or unwise decision-making or poor planning, and perhaps neglect plus complacency ("we won't bother checking the take-off distance, we'll be OK!) figure prominently as causal factors in those accidents. Accidents also happen when we attempt to operate in circumstances beyond our experience and/or ability. Quite often, just two or three misjudgements, possibly not that significant in themselves and sometimes combined with a bit of bad luck, lead on to a heap of wreckage. And, of course, there are those few occasions where pilot incapacitation is possibly the cause.

For those older members be aware that our abilities (including judgemental ability) and both the speed and appropriateness of our reactions does continue to deteriorate as we age, but some tend to deny it to themselves and to others. (Speaking as an octogenerian who has been able to observe the ageing process on myself and acquaintances for quite a number of years). One acquaintance of similar age told me 'I am still licensed but don't fly pilot-in-command any more – found myself making too many small mistakes and figured I'd better quit before I made the big one'.

We — the entire sport and recreational aviation community — must do all we can to bring the number of all such accidents to zero. Fatalities are not inevitable, even an engine failure over heavily forested terrain is survivable and, possibly, some forms of pilot incapacitation accidents could be avoided if pilots follow the pre-flight safety and legality check procedures. Non-conformity to the appropriate aircraft maintenance schedule and procedures is high-risk. Of course there are events that an individual pilot might have little control over, such as a bird strike at a critical time or being struck by an overtaking aircraft on final approach, but again, there may be aspects of situational awareness involved.

So, the only statistic that sport and recreational aviation should be striving for is 'zero'; no fatal accidents and no disabling injuries.
'Pilot error'
The term appears extensively in safety investigation reports but is often a most unsatisfactory summation of an event and its causal factors; in some cases a police accident investigator can be led to conclude, quite incorrectly, that an accident cause was 'pilot error'; see this Findings of Inquest. In the 1980s the International Civil Aviation Organization [ICAO] — the administrative authority for the world's international air transport system — finally accepted the inevitability of some human error in flight, maintenance and other aviation operations. Consequently, in 1989 ICAO introduced a 'human factors' training and assessment requirement for pilots (and others) and circular 227-AN/136 'Training of operational personnel in human factors' was issued. In 2008, RA-Aus, at last introduced human factors to the flight training syllabus.

The Australian Civil Aviation Safety Authority also decided that, from 1 July 2009, 'threat and error management' would be added to the existing human factor aeronautical knowledge examinations, within the day VFR syllabus. A Civil Aviation Advisory Publication CAAP 5.59-1(0) 'Teaching and Assessing Single-Pilot Human Factors and Threat and Error Management' was published in October 2008 and is recommended reading.
AUF/RA-Aus fatal accident statistics 1985 to 30 July 2015
There were 149 fatal accidents during the 31 year period 1985 through July 2015. The following bar chart shows the annual distribution of those fatal accidents while the chart line has the effect of smoothing the data by displaying a 4-year running average; the first 4-year period commencing in 1985.

Accident statistics

The ultralight pioneers were having terrible problems in the formative years of the 1980s (roughly one fatality per annum per 250 members). 90% of the fatal accidents then occurred in ANO 95.10 aircraft; the remainder in ANO 95.25 aircraft. There were about 18 fatal ultralight accidents reported to BASI during 1980 to 1984, then 30 fatal accidents in the period 1985 through 1989 during which period membership grew from around 800 to 2200. The recommendations of the House of Representatives Standing Committee on Transport Safety 'Report on Sports Aviation Safety' began having effect in 1988. The fatal accident rate in those years is not comparable with the current recreational aviation scene as, prior to 1988, the aviation regulations stupidly forced those pioneers to confine their operations to that most dangerous altitude band of no higher than 500 feet above ground level. CAOs 95.32 and 95.55 were introduced in 1990.

During the 8-year period 1992 to 1999 AUF ordinary (i.e. voting) membership plateaued at around 3500; the membership turnover was low, pilot training — and the improved availability of choice in aircraft — started to take effect and the fatal accident numbers decreased steadily each year. CAO 95.10, CAO 95.25 and CAO 101.55 types each contributed about 25% of the accidents, with the remaining 25% split evenly between CAO 95.32 and CAO 101.28 aircraft. The factory-built types (95.25, 95.32 and 101.55) were involved in 62% of fatal accidents, and the home-builts in 38%.

However, in 1998 the advanced 544 kg 'AUF amateur-built (experimental) ultralight' (the 19-xxxx registrations) was introduced, which did much to provide the platform on which the rather astounding AUF/RA-Aus expansion was based. But this expansion also led to an alarming increase in the number of fatal accidents during the period 2000 through 2006. The amateur-built aircraft figured in 47% of fatal accidents, other home-builts in 10% and factory-builts in 43%, reversing the home-built/factory-built distribution of the 1992 to 1999 period.

1.2 Are we getting safer?

Recent history 2007-2015
No RA-Aus pilot believes that they will die in an aircraft accident, but the fact remains that during the last 5 years – a period of consolidation rather than expansion of membership and aircraft numbers – the average yearly fatalities are seven pilots and two other occupants, about double the deaths in that prior 5-year period of continuing growth.

Note: I occasionally mention an accident causing severe injuries in the following notes but those represent only a few of such accidents where pilots and passengers are admitted to hospital with severe – possibly disabling/disfiguring – injuries. I don't have any reliable statistics for such events but I expect they would exceed the number of fatal accidents; ATSB describes a severe injury as one where the person requires hospitalisation within seven days of the accident.

In 2007 RA-Aus membership was still increasing at an annual rate around 13%, which resulted in almost 7800 members at the end of the year. Sadly, 2007 ended as our worst year recorded to that date — eight fatal accidents in which 13 people died, eight pilots and five passengers. In addition there were two other accidents where three occupants were severely injured. A passenger died in nearly two-thirds of the fatal accidents, recording a disastrous increase in such casualties.

However, 2008 recorded a great improvement. There was only one fatal accident in an RA-Aus registered aircraft during the year, but sadly both occupants died. There were two accidents where the pilots sustained severe injuries. Since the AUF/RA-Aus was established in 1983 there has been one other year (1996) where only one fatal accident occurred. The average number of aircraft on the register during 2008 was 2850, a 230% increase in aircraft since 1996 so, considering that, 2008 was our safest flying year ever. But the combined 2007 and 2008 total was still nine fatal accidents in which 15 people died. The average annual number of fatal accidents for the four-year period 2005-2008 was 4.5 — less than the 6.0 for the 2001 to 2004 period.

The 2009 year started very well; there were no fatal accidents in the first seven months and it looked like the human factors training programs introduced in 2008 were starting to produce the required results. Then there were four fatal accidents between August and December. Two of the accidents involved trikes and a passenger also died in one of the trike accidents. In addition, there was a fifth accident where an RA-Aus three-axis pilot died in a trike registered with HGFA. There were five accidents in which an occupant suffered severe injury. So, a year that started with a lot of promise ended very badly; in effect maintaining the historical average annual number of fatal accidents. The number of aircraft on the RA-Aus register at the end of 2009 was 2955 and there were 9186 ordinary members.

There were three RA-Aus fatal accidents in 2010 causing the deaths of three pilots and one passenger, while another passenger was severely injured. Four persons were severely injured in three other accidents.

The 2011 year started very badly with two fatal accidents in January and continued in that vein throughout the year to total six fatal accidents. The death toll was eight — five certificated pilots, one student pilot under instruction (i.e. an instructor was in command) and two passengers. It was another very bad year, but it could have been horrific — it was only extraordinarily good fortune that there were no serious casualties when an RA-Aus aircraft, with two persons on board, flew into an operating fairground Ferris wheel. See the Australian Transport Safety Bureau final report.

There were three fatal accidents in the first half of 2012 but none during the remainder, two of the accidents involved trikes. The death toll was five — two pilots and a passenger in the trikes, an instructor and a pilot-under-instruction in a Sportcruiser (PiperSport). The 4-year moving average accident rate is now 4.0 per annum, much the same as it had been for the previous four years.

2013 was a disastrous year, we experienced a stunning tally of 11 pilot and two passenger fatalities, a magnitude we have never experienced before. Those 11 fatal accidents are just one less than the total accidents during all of 2010, 2011 and 2012 and increased the annual average to 5.8 p.a. for the four years 2010 through 2013.

During 2014 there were six fatal accidents in which eight persons died; six pilots, one passenger and one pilot examiner conducting a biennial flight review, increasing the 5-year average to 6.5 p.a. A small child passenger was severely injured in one of the fatal accidents.

To date (1 August 2015) there have been 7 fatal accidents in 2015 in which 8 pilots have died, but thankfully no passengers. One of the accidents involved the worst type of pilot error – a mid-air collision between a Thruster and a Drifter flying in company during a local recreational flight, resulting in the death of both pilots. Not included in these figures is a fatal accident in a nominally non-RAAO associated powered-parachute aircraft that had been allocated an RA-Aus registration number for construction. If there are no further accidents during August to December 2015* those 7 (or 8?) accidents will increase the RA-Aus 4-year (2012-2015) average to 7.3 p.a.

*Historically the 3rd quarter of the year has the least accidents but there doesn't appear to be any seasonal influence in the accident rate for the 1st, 2nd and 4th quarters, though there is a tradition (but little backing data) that the 4th quarter has the worst record.
The powered recreational aviation scene: 36 deaths in the last 31 months!
Of course RA-Aus is not the only association where recreational pilots operate powered aircraft under the exemption CAOs. HGFA pilots also operate trikes under CAO 95.10 and CAO 95.32 plus powered hang-gliders and powered paragliders under CAO 95.8. Also there are non-associated pilots who operate outside an RAAO and thus not under an exemption CAO, i.e. the persons who have inadvertently or deliberately allowed membership/registration to lapse or the few who have never bothered to join RA-Aus/HGFA. The rotary wing gyroplanes operated by Australian Sport Rotorcraft Association members have not been included.

Using this broader approach to 3-axis and weight-shift controlled powered aircraft operated by RA-Aus and HGFA members – plus the non-associated fliers – then the total fatalities in just the 31 months – January 2013 to July 2015 inclusive – has reached the very disturbing total of 36 persons – 31 pilots-in-command (25 RA-Aus, 5 HGFA, 1 non-associated), one RA-Aus pilot examiner and 4 passengers (3 RA-Aus, 1 HGFA); 29 of the deaths were associated with RA-Aus, 6 with HGFA and 1 non-associated, the latter seems to have, perhaps inadvertently, allowed RA-Aus documentation to lapse. This broader presentation reflects powered recreational aviation as the general public sees it.

The answer to the question — "Does it look like recreational aviators are now getting safer and that there is less chance of fatal accidents?" — is that they are most certainly not getting safer, despite the 2008 introduction of human factors training and the more recent managerial measures — and despite some recent RA-Aus board member statements. Four of the recent RA-Aus fatal accidents involved non-recreational stock and station air work operations, which reflects the lack of compulsory training in such work.

Assuredly, we are not improving; perhaps the adage 'The more things change, the more they stay the same' is appropriate?

Comparison of the RA-Aus accident rate and the total annual flight hours
The following bar and line chart is derived from the annual number of RA-Aus fatal accidents and the total annual aircraft flight hours (reported by aircraft owners at the time annual registration is renewed) to provide the number of fatal accidents per 100 000 flight hours. RA-Aus staff, of course, presume that the annual aircraft flying hours reported by the owners is reasonably accurate. The bars* indicate the number of fatal accidents divided by the number of 100 000 flight hour blocks flown that year and the line indicates a four-year running average of the annual rates.

* For example, if there were four accidents in a year when 75 000 flight hours were recorded the calculation would be 4/0.75=5.3 accidents per 100k flight hours.

Accident statistics

The pattern is interesting. The fatal accident rate per 100k flight hours peaked in 2002* and in the 4-year period 2000-2003, when we were averaging nearly 80 000 flight hours per year, the fatal accident rate was 7.2 per 100k hours, which was nearly as bad as the toll in the early 1980s (which prompted the investigation by the House of Representatives Standing Committee on Transport Safety). During the 2004-2007 period flight hours averaged about 110 000 hours annually and the rate reduced to 5.1 per 100k hours. Then in 2008-2011, when flight hours increased to around 155 000 per annum, there was a big improvement to 2.4 accidents per 100k hours. RA-Aus report 482 000 flight hours accumulated during 2012, 2013, 2014 and I have guessed 100 000 hours for the first 7 months of 2015 so with the 29 fatal accidents recorded for that period, then the rate has jumped up again to 5.4 fatals per 100k flight hours, so we seem to be reverting towards where we were in 2004-2007. A very poor result, particularly considering all the work that has been done.

*Note: in 2002 the CAO 95.10, 95.25, 101.28 and 101.55 aircraft accounted for about 75% of hours flown, but by 2012 those aircraft represented less than 10% of flight hours.
So, what are the reasons?
RA-Aus introduced human factors (HF) training in 2008 and from August that year all student pilots were studying HF in their training and all existing Pilot Certificate holders were required to complete an HF course, or just an examination, by August 2010.

Obviously RA-Aus pilots are still not getting the message. HF training is part of airmanship development and is not designed to worsen the safety record, so there must be something wrong in the RA-Aus HF training syllabus — and/or lacking in its implementation by the flight schools and/or in the quality assurance assessment outcome — of both the association's HF training for student pilots and the 2010 HF 'examination' of the, then existing, certificated pilots.

In addition, there are concerns whether it was appropriate for the RA-Aus board to persist in its long-standing failure to rapidly disseminate some factual information concerning the occurrence of a serious accident, and the later distribution of the RA-Aus accident investigator's report containing the causal factors. The situation has been that the fatal accidents were not mentioned by the Board executive or RA-Aus management in the website news section or the monthly journal 'Sport Pilot'; not even when the member concerned was well known to, and well respected by, the broad membership. The RA-Aus has not negotiated any arrangement with the State Coroners to allow the fast distribution of some factual causal factor information to the membership – for all fatal accidents – without having to wait, possibly up to six years, for the release of just those rather few, non-restricted, coronial findings. The unpublished policy was that it was left to the membership to learn of the event via the public media's uninformed reports and the internet forums' sometimes grossly speculative chatter, and thus the membership learned nothing of real value from the accident, except, when necessary — but very occasionally — an aircraft airworthiness notice might be issued as a result of the RA-Aus investigative work. All they learned is that their elected representatives did not choose to provide factual causal factor information to the members they represented! Certainly, this negative attitude was doing absolutely nothing to improve safety outcomes and the governance of the Association was neglectful of member and passenger safety — including the safety of those members who need to be protected from their own wilful actions, possibly by re-training or grounding them for a period.

There has been considerable tumult in the Board during the past few years and this seems to have contributed to an unusually high turnover in Board members and in the staff, reaching the point where concerns about an apparent lack of corporate knowledge are apparent. For example, the RA-Aus President's report appearing in the July 2014 issue of the monthly RA-Aus members' journal 'Sport Pilot' contained this statement:

"The data used in the [Aviation Safety Regulation Review Panel] report covers the period 2008 - 2013. Our fatality rate over this period is pretty steady and some could argue that, aside from 2013, it is downward trending. This is somewhat reassuring and suggests that as pilots (and other participants in our sport) we are less likely to be killed today than we were some years back. To me this is a great result."

The ASRR report data referred to purposely excluded all weight-shift controlled aircraft (and stated so) and also did not include other fatal accidents that had not been reported to the ATSB, so the report failed to list eight of the fatal accidents that occurred in 2011 - 2013 and of course 2013, with 13 deaths, was the worst accident year ever recorded and assuredly not 'a great result'. The President's rather odd statement disclosed a notable lack of knowledge ot the RA-Aus fatal accident history and consequently would misinform/mislead those RA-Aus members who were not better informed than he. Perhaps the reason the membership is not 'getting the message' is that the reality is not being publicised vigorously enough in the members' monthly journal and in www.raa.asn.au?

The RA-Aus safety management system still seems ineffective. See page 12 of CASA's Sport Aviation Self-administration Handbook 2010 for the elements of a safety management system; also see the text of the 2012-2013 and 2013-2014 CASA/RA-Aus Deeds of Agreement in the members section of www.raa.asn.au.

Paragraph B.7 in the statement of purpose section of the RA-Aus constitution is a reminder to all ordinary members and all board members. It states: "To set promote and maintain standards of safety for recreational aircraft by the specification and dissemination of information concerning standards of airworthiness for aircraft, standards of workshops and standards of knowledge for pilots and in particular, to specify, impose and enforce standards of skill and competence reactive to all stages of flying operations and to require any Member to meet such standards to the satisfaction of the Association before authorising such Member to engage in flight operations or any stage or aspect thereof and to grant, issue authorise, modify, cancel, suspend or revoke under the rules of the Association for the time being in force certificates and authorisations relating to aircraft, aerodromes, flying instructing and flying schools and to the skill and qualifications of pilots, instructors, navigators, drivers, mechanics and all persons managing, flying, driving, constructing, repairing or otherwise engaged in connection with recreational aircraft or recreational activities and to do all things relating thereto as may be deemed expedient and to make reports and recommendations to any clubs, authorities or persons concerning the same."

I leave it to the reader's own experience to judge whether the actions stipulated by paragraph B.7 are currently being carried out and, as B.7 contains the constitution's sole reference to 'safety' , does the constitution as drafted really express any concern with the need for an effective safety management system and the ongoing safety (and safety education) of all the membership and their so-called 'informed participant' passengers?

Six passengers (plus one pilot examiner and two student pilots under instruction) died during 2011-2014 which raises the point of how is a passenger made aware of the potential risks inherent in sport and recreational aviation so he/she can make an informed decision about their participation? Various rather bland warning placards, not particularly addressed to the passenger, must be displayed in the aircraft cockpit, but that's hardly sufficient. As the association chooses not to report any information regarding persons fatally or severely injured — for the pilot to include in the pre-flight passenger briefing — how can any person, even the pilot, be regarded as well informed? Can a young passenger make an informed decision? The association doesn't even actively pursue the wearing of suitable safety helmets in flight, particularly for passengers.
The role of the Australian Transport Safety Bureau
All recreational aircraft accidents/incidents are, or should be, reported to the Australian Transport Safety Bureau. Section 12AB of the Transport Safety Investigation Act 2003 states 'the ATSB is not subject to direction from anyone in relation to the performance of its functions or the exercise of its powers'. Thus a coroner cannot control the release of information by the ATSB.

Unfortunately ATSB is not a large organisation, perhaps around 100 personnel (it was required to reduce its numbers by about 10% in 2014) and is also responsible for rail and marine safety investigations. It is rather obvious that ATSB lacks the resources to investigate recreational aircraft accidents, fatal or otherwise, and will not do so unless it considers the safety of the general public may have been threatened or private property damaged. ATSB does provide valuable laboratory assistance to RA-Aus investigations in the fields of metallurgical testing, extract of data from avionics etc.

*In a May 20, 2013 document titled 'Focusing our investigative resources' Martin Dolan, the Chief Commissioner and CEO of the Australian Transport Safety Bureau wrote:

'We often get asked how we decide whether to investigate a particular accident or incident that's reported to us.
... we direct our investigative resources to accidents and incidents involving operations that have mature safety systems and will likely uncover a safety benefit or improvement for industry and the travelling public.

... As a result, we generally do not investigate private activities such as sport and recreational flying where there is a voluntary acceptance of a higher level of risk. Those sectors of aviation are largely self-administering and have their own investigation capabilities, working with the police and coroners in the case of fatal accidents.

... When an accident has a high public profile, though, that is one of the considerations we openly take account of in deciding whether to investigate. We recognise that the community sometimes expects we will try and find out what happened, even when it's unlikely that we'll learn something to improve safety. '

ATSB perceives RA-Aus as the organisation responsible for investigating RA-Aus fatal accidents, which results in a negative impact on the dissemination of information to the RA-Aus membership because coroners, in turn, only regard the RA-Aus investigators as part of the police investigation team assisting coroners and thus subject to coronial control in respect to dissemination of their fatal accident investigation reports. Our investigators should be regarded as RA-Aus members trained and appointed by RA-Aus management to do the crash investigation on behalf of the general RA-Aus membership and, to some extent, on behalf of the ATSB.
The effect of delayed dissemination or non-dissemination of information from coronial investigations
The state police services have coronial jurisdiction to manage and control the site of a fatal recreational aircraft accident thereby preventing unauthorised entry, locating deceased or injured persons, arranging attendance of a medical authority and the transport of deceased or injured persons and, subsequently, coordinating the initial accident investigation. Police may invite participation of accident investigators from a recreational aviation administration organisation. Fatalities are reported to the coroner as a 'non-suspicious reportable death' and the police will maintain charge of the aircraft wreckage until all coronial procedures are concluded. The coroner may be a full-time coroner or a magistrate coroner who will advise the officer in charge as to whether or not further police investigation is required and perhaps order a post mortem examination.

The coroner will investigate – with the further aid of police, other investigators and witnesses – the circumstances surrounding the death. For a reportable death the law requires the coroner to establish the identity of the deceased; the medical cause of death (e.g. fatal injuries sustained in an aviation accident); when and where the death occurred and the circumstances surrounding the death i.e. what caused, or contributed to, the aircraft accident. After concluding an initial investigation a coroner may issue his or her findings without holding an inquest ('Findings without inquest') but an inquest may be held if the coroner believes it is in the public interest to do so and/or a 'senior' relative of the deceased requests it. The coroner maintains contact with the family during the coronial process.

About 15% (22 000 p.a.) of all deaths in Australia are investigated by coroners of which perhaps less than 3000 result in a coronial inquest. An inquest is a public enquiry by a coroner's court into the cause of a death where various persons associated with the event, or persons thought able to provide 'expert' input, are required to attend and be questioned as witnesses. The coroner's findings, whether 'Findings of inquest' or 'Findings without inquest', may include recommendations to authorities in regard to systems, procedures and regulations with the intention of reducing the likelihood of similar accidents in the future. The coroner will also deliver a cause of death document to the state registrar of births, marriages and deaths, thus enabling the family to obtain the death certificate needed to finalise legal arrangements.

However a full coronial investigation is a long (sometimes unbelievably long) but worthwhile, legal process. For example, the coroner's findings from the inquest into the death of research scientist Doctor Barry Uscinski provide informative, perhaps disturbing, reading; but the time elapsed between the accident and release of these findings was 50 months. The police investigator's report concluded that the accident was due to pilot error however the coroner had doubts and the family requested an inquest. The Findings of Inquest, determining that the accident was not due to pilot error, can be read at www.courts.qld.gov.au/__data/assets/pdf_file/0005/337622/cif-uscinski-20141229.pdf". The RA-Aus investigator's opinions as an expert witness seem to form the basis of the coronial findings.

Surprisingly 'Findings without inquest' might also take a similar period to be published; for example, see the non-inquest findings for the Zenith Zodiac CH601 crash off Surfers Paradise in March 2008. Although this aircraft was VH registered the ATSB passed it on to RA-Aus thus confirming ATSB's good regard for RA-Aus investigative capabilities. RA-Aus was asked to assist the police investigation and it seems the coroner based his findings on the RA-Aus conclusions. The findings were published in October 2014 (6 years and 7 months after the accident) although in January 2009, RA-Aus issued an airworthiness notice AN070109-1 titled 'Compulsory fitment of a secondary canopy locking device, on Zodiac/Zenair/Zenith aircraft canopy'. This AN just states 'Several reports have been received indicating that the canopy fitted to Zodiac/Zenair /Zenith aircraft are opening in flight causing air turbulence around the tailplane and elevators' and does not mention that the death of two persons 10 months earlier was most likely caused by canopy detachment. Choosing this soft approach rather than making a statement providing more impact on RA-Aus members may have been done to avoid pre-empting the coroner's findings however a bit of judicious wording could have informed the membership of the likelihood of canopy detachment being involved in the deaths of two persons.

The findings of the inquest into the death of Philip Henry Scholl took 39 months to publish but are well worth reading, particularly for any member contemplating purchase of a second-hand trike.

However the bulk of coroners' findings are not publicly available, distribution being restricted to the next-of-kin and perhaps the police and associated investigators. It is not easy to locate the remaining non-restricted coronial findings on the internet; for example the RA-Aus website contains only two references* to coronial findings, one reveals 32 months between the accident and the date of the finding, the other is 54 months. Obviously a report on an event that occurred 4-6 years previously would be regarded as history by most RA-Aus members reading the coronial findings (particularly those many members who joined the association well after the reported accidents). Grossly delayed accident reporting lacks immediacy in its impact on the membership. It appears that the current national standard for coroners’ courts is that no lodgements pending completion are to be more than 24 months old, so perhaps recreational aviation accidents are regarded as less important and tend to drift toward the back-burner.

*The fact that the RA-Aus website contains only two references to unrestricted coronial findings is rather strange as one would presume RA-Aus, as active participants in the coronial investigations, would be on the distribution list when the findings are published.

Fatal recreational aviation accidents keep accumulating while coronial investigations drag on. The Doctor Barry Uscinski inquiry took 50 months to complete but in a 50 month period between January 2011 and February 2015 inclusive, 29 RA-Aus accidents killed 38 persons and destroyed 30 aircraft. On top of that it was only extraordinarily good fortune that the October 2011 controlled flight collision with an operating Ferris wheel at Old Bar, NSW did not add members of the public at large to the toll.
Self-education - a good pilot is always learning
The supply of material for self-education is most important. Martin Dolan, the Chief Commissioner and CEO of the Australian Transport Safety Bureau wrote (May 17, 2013 in answer to a query concerning boating accidents): 'In many cases they reflect what we see with smaller aircraft: the same accidents happening over and over. The best way to tackle these problems would seem to involve clear, targeted safety education [JB's emphasis] about how accidents can be avoided – as many of them are easily avoidable.'

The RA-Aus constitution should require dissemination to the membership, as one form of safety education, those very valuable RA-Aus investigator reports that summarise the facts and the investigator's conclusions. Accident investigator's reports were last published in the AUF website in 2004. The following are previously published examples of AUF investigators reports, without the photographs. You will note that the reports do not name any persons.

Recreational aviators are most certainly not getting safer, possibly the biggest problem is that many, perhaps most, pilots seem to have a feeling of invulnerability believing 'it can't happen to me!' We don't need regulatory changes; recreational aviators need more self-motivation and more consistent, continuing self-education – including some shock treatment. Probably only extensive, graphic and persistent publication of the causal factors and the resultant wreckage of all 82 fatal accidents that have occurred since January 2001, plus a link to the relevant coroner's findings if available, might provide sufficient shock value when printed and distributed to all RA-Aus Pilot Certificate holders. Such material, when seen by their own family members, could place additional pressure on recreational pilots to add improved discipline to their flight activities.

I expect the families of fatal accident victims, if approached sensitively, would support such publications; I'm sure they would wish to reduce the number of families that will undoubtably undergo the suffering and hardship that they have experienced.

1.3 I'm a good pilot; I have my pilot certificate, my endorsements and 100s of hours; I feel I am competent enough and sensible enough to avoid an accident, why should I worry?

Competency is more than making an excellent landing after a calm flight around the area in fair weather. It has been defined as the combination of knowledge, skills and attitude required to perform a task well — or to operate an aircraft safely and in all foreseeable situations. A flight operation — even in the most basic low-momentum ultralight aircraft — is a complex interaction of pilot, machine, practical physics, airspace structures, traffic, atmospheric conditions, planning and risk. When each and every flight is undertaken it is not only the aircraft that should be assessed for airworthiness; the total environment — airframe, engine, avionics, pilot, atmospheric conditions and flight planning (even the simple planning of how a local fun flight will be conducted) — must support the safe, successful conclusion of each operation.

A good pilot never stops learning. The remarks of an instructor, following a very hazardous landing on icy grass, are pertinent: "I have been flying for 45 years and been an RA-Aus instructor for 12 years, but that flight taught me THERE IS ALWAYS MORE TO LEARN".

Airmanship is the cornerstone of pilot competency. It is the perception — founded on the acquired underpinning knowledge — of the state of that total environment and its potential risks that provides the basis for good airmanship and safe, efficient, error-free flight.

Good airmanship is that indefinable something, perhaps just a state of mind, that separates the superior airman/airwoman from the average. It is not a measure of skill or technique or hours flown, nor is it just common sense (i.e. 'good sense and sound judgment in practical matters'); rather it is a measure of a person's awareness of the aircraft and the current flight environment, and of their own capabilities and behavioural characteristics, combined with sound judgement, wise decision-making, attention to detail and a high sense of self-discipline.

For example: "The aircraft, with instructor and student on board, was returning to the airfield when a pitch-down occurred; not known to them the elevator control horn assembly had failed. Control stick and trim inputs failed to correct the situation, but a reduction in power did have a correcting influence, although not enough to regain level flight. A satisfactory flight condition was achieved by the pilots pushing their bodies back as far as possible and hanging their arms rearward. A successful landing at the airfield was accomplished."

Insufficient perception, poor judgement (e.g.'I think I can make it!' or worse, 'I think I can make it this time!'), complacency (e.g. 'It'll be OK!') and insufficient self-discipline create a pilot very much at risk.

1.4 What kind of flying makes up your hours?

Do you often practise engine failure procedures, accelerated stall/unusual attitude recoveries, precise turns and so on, or have you just continually repeated the same operation? Do you try to improve your skills in each flight? Are you aspiring to recognise threats and errors, and manage the risk?

Most sport and recreational pilots, as with most general aviation recreational pilots, accumulate only a small number of hours each year. The average annual hours currently reported by RA-Aus Pilot Certificate holders, excluding instructors and students, is only 35 hours; which means that about 50% are flying less than 35 hours. Aircraft owners would put in more hours, aircraft hirers less hours. Perhaps 30 to 40 annual flight hours is enough to maintain just those physical flying skills learned at the ab initio flight school — if the pilot has established a program for self-maintenance of that level of proficiency — but maybe not enough to maintain a high level of cognitive skills: for example situation awareness, judgement and action formulation.

Note: the average annual hours flown by RA-Aus aircraft during the last 15 years — including the flight school machines — ranges from 44 to 60, but most years are between 50 and 55 hours, though, of course, some might accumulate ten times that number. Of course, at any time, there are numbers of Pilot Certificate holders – even aircraft owners – who may not have flown for 6 months or more and their lack of recency adds significant risk to flight.

The difficult decision for many recreational pilots lies in the situation that, for various reasons, they are only able to undertake those few flight hours. Should flying for enjoyment take a back-seat to the imperative for skill improvement and further inflight educational training?

In addition, having completed flight theory studies sufficient to pass the basic aeronautical knowledge test and achieve the Pilot Certificate, it seems that many, perhaps most, pilots leave it at that, failing to expand their knowledge by further in-depth studies of flight dynamics — or even ultralight essentials like microscale meteorology. Possibly because it involves sometimes difficult detail rather than the broad-brush approach of the flight school manual, and perhaps assuming that such knowledge will be accumulated through subsequent flight experience — also hoping, I guess, that they will inherently know how to survive every learning experience.

For example, here is a learning experience that the trike instructor was lucky to escape from relatively unscathed, as was his paying passenger: "the pilot intended to conduct a trial instructional flight from a grass strip over 250 metres long. The strip was soft after rain but several solo take-offs had been carried out, each clearing the fence at the end of the strip by 75–100 feet. After some test runs with the passenger on board the pilot elected to take-off using a short field technique. The aircraft accelerated until the nose wheel lifted off the ground and then slowed — with the nose wheel sinking back onto the ground. Because he still believed he had sufficient speed in hand, the pilot tried to make it over the fence; but tripped over it. The aircraft was destroyed."

Like the 'Sunday driver', many pilots are just continually repeating the same flight experience — each year is much the same as the last — so all they accumulate is a repetition of one year's experience. They have no program of deliberately accumulating advanced knowledge or skills, nor have they really absorbed the safety basics that should have been instilled into them over the years: always maintain a safe attitude and a safe airspeed when operating at lower levels; if the engine has been misbehaving never take off until the problem is identified and fixed; if the engine goes sick in flight, don't try to make it back to base — land as soon as feasible; don't continue flight into marginal conditions; and so on.

The bulk of recreational aviation is undertaken by 'amateur' pilots (using the original meaning of the term; i.e. a lover of a particular activity or pastime) with modest piloting skills. But such pilots, whether PPL or Pilot Certificate holders, must still approach aviation with the attitude of a professional.

Too many pilots regard their biennial flight review as a bit of a nuisance, rather than demanding from the reviewer a professional in-depth audit of their competency. Beware your 'friend' the examiner who waives the flight check because he/she is satisfied, by 'discussion and observation', that you are competent. Pay to do the check in a two-seater if your own aircraft is single-seat.

1.5 So does a safety problem exist with 'experienced' pilots?

Some, perhaps many, pilots are just not ensuring that they continue to accumulate adequate post-Certificate knowledge and skills. In short they never really learn much more about flight dynamics and they lack other pertinent knowledge; and worse, they are just not listening and hearing. On the other hand, there are the very puzzling instances, where those who might be regarded as very experienced and knowledgeable, expose themselves to extreme risk — when surely they know the dice are loaded against them?

For instance we have the 10 000 hour pilot who lost his life and that of his passenger near the top of the Great Dividing Range, possibly just because he believed "We can make it under the cloud base!" What may have contributed to that belief and may have led to that possible decision? We just don't know; the only certainty was the location of the wreckage.

Some accumulated beliefs may be dangerously false. For example, the long-time pilot who is convinced that a very light aircraft, caught in a strong lee-side downflow, will always be safe because it will 'go with the flow' when the downflow flattens out near the bottom of the slope.

The sound pilot must understand how the environment parts relate and interact with each other, and judge the likely consequences of any action, deliberate non-action or random event. A systematic approach to continuing improvement in airmanship, plus self-discipline and an ability for self-appraisal, is necessary to achieve that understanding. Don't expect that you can enrol for advanced flight training and somehow that training will reduce your risk exposure to minimum levels. Certainly it will help, but risk management/decision-making is very much in your own hands – do not ignore those rather simple rules that have been established by the cumulative experiences of the pilots that have gone before you during the 110 years of powered aviation history.

The Flight Manual or Pilot's Operating Handbook for the aircraft model being flown must be fully understood, and the content recollectable, when needed in an emergency. You must be totally familiar with the fuel and electrical systems. For an aircraft type that is regularly flown every switch, knob and lever position must be instantly locatable and identifiable without having to hunt for it. Can you find the alternate static vent lever by feel only? Every item in the pre-start and pre-take-off check-lists should be physically verified before opening the throttle — EVERY TIME. It's often the pilot who doesn't do the full checks — because he (usually a male) did them only an hour ago — that gets caught out. Every flight should be prepared and conducted correctly and precisely, using procedures appropriate to the airspace class and without taking shortcuts — even if just a circuit and landing or flight over to the neighbour's strip is contemplated.

Pilots should be aware that fatigue, anxiety, emotional state — or flying an aircraft that stretches their skill level, or just flying an aircraft they don't like — will affect perception, good judgement and wise decision-making. If you lack flight experience in a wide range of aircraft types you may find that you have insufficient skill to handle an aircraft that introduces new flight behaviour characteristics and which you are flying for the first time, see this Darwin Coroner's finding resulting from a trike accident (14 months previously).

Most studies of aircraft accidents or incidents reveal not a single cause but a series of interrelated events, warnings or actions which, being allowed to progress without appropriate intervention, march on to a possibly catastrophic crash site. Sometimes the final trigger may be relatively innocuous, but sufficient in itself to totally remove a safety margin previously eroded by other events. A U.S. Navy pilot once wrote "In aviation you very rarely get your head bitten off by a tiger — you usually get nibbled to death by ducks." However U.S. Navy pilots are well-trained, well-informed, self-disciplined team players who do not expose themselves to those situations where the tiger concealed out there WILL leap out and bite your head off.

For example, take the young male pilot, deemed to have been above average at his flight school two years previously and thought likely to become a very capable aviator, who — in a fit of exuberant youthful bravado — succumbed to temptation and took his equally young female friend for a totally illegal non-qualified low flying demonstration in a RANS Coyote and, when a wingtip hit a fence line, ended two lives before they had hardly begun, and deeply scarred the lives of the people who loved them. Non-qualified low flying is a killer; checking stock, mustering, checking tanks, buzzing houses, beating-up airfields, low-level photography and powerline collisions all figure actively in accident reports.

Many years ago, the Australian gliding community demonstrated that there were two main cyclic periods (for them) where people were accident prone. This was about the 100-hour mark, where pilots were beginning to think they were immortal, and about 200-250 hours when they were sure they were; being survivors of the incidents of the first period. Other aviation organisations have indicated similar findings in the 50 to 350 hour period.

The next article is titled 'Don't fly real fast'

'Decreasing your exposure to risk' articles

| Introduction and contents | Recent RA-Aus accident history | Don't fly real fast | Don't stall and spin in from a turn |

| Don't land too fast in an emergency | Engine failure after take-off | The turn back: possible or impossible — or just unwise? |

| Wind shear and turbulence |

Copyright © 2007–2015 John Brandon     [contact information]