Temora crash - lessons

[turboplanner]

CASA is not involved in investigating accidents

 

The ATSB (Federal Government) investigates GA accidents and their investigations are made public.

 

The ATSB does not investigate RA accidents; they are investigated by Police.

 

Hence we have this hypocritical situation where a GA fatality gets a fairly quick Interim report on the ATSB website, and a very detailed final report, but an RA fatality is never heard of again. Sure there is a Coroner's report, but that can go in quite a different direction to an investigation like that of the ATSB which produces useful information on the background and the events of the incident.

 

 

[David Isaac]

Knowing how meticulous David was and the preparation that went into this flight, the fact that the planning and flight was executed in tandem with his CFI and how eminently qualified his CFI was, I am certain this accident will not be one of human error on David's part.

 

The aircraft appears to have arrived at extremely high speed in an almost vertical plane and has been completely destroyed by fire.

 

For my way of thinking the cause is likely to have been one of three possibilities (and please forgive my speculation).

 

1. Catastrophic medical incident (David was almost 59), this could happen to any of us, and there is little we can do about it if undiagnosed.

 

2. Catastrophic structural failure.

 

3. Fire in flight that destroyed the wing.

 

Peter will no doubt be able to provide information if he saw David go in. I feel terribly for Peter under these circumstances, it must have been traumatic to the extreme to watch your friend go in and know he could not possibly have survived.

 

 

[dazza 38]

Knowing how meticulous David was and the preparation that went into this flight, the fact that the planning and flight was executed in tandem with his CFI and how eminently qualified his CFI was, I am certain this accident will not be one of human error on David's part.The aircraft appears to have arrived at extremely high speed in an almost vertical plane and has been completely destroyed by fire.

 

For my way of thinking the cause is likely to have been one of three possibilities (and please forgive my speculation).

 

1. Catastrophic medical incident (David was almost 59), this could happen to any of us, and there is little we can do about it if undiagnosed.

 

2. Catastrophic structural failure.

 

3. Fire in flight that destroyed the wing.

 

Peter will no doubt be able to provide information if he saw David go in. I feel terribly for Peter under these circumstances, it must have been traumatic to the extreme to watch your friend go in and know he could not possibly have survived.

Good to here from you mate

 

 

[campslive]

Just a point of etiquette Graham, all capitals is considered as shouting and therefore a no-no for normal conversations. Caps off please.

sorry doug was writing with a very heavy heart didnt even notice caps lock on

sorry mate

 

graham

 

 

[Camel]

CASA is not involved in investigating accidentsThe ATSB (Federal Government) investigates GA accidents and their investigations are made public.

 

The ATSB does not investigate RA accidents; they are investigated by Police.

 

Hence we have this hypocritical situation where a GA fatality gets a fairly quick Interim report on the ATSB website, and a very detailed final report, but an RA fatality is never heard of again. Sure there is a Coroner's report, but that can go in quite a different direction to an investigation like that of the ATSB which produces useful information on the background and the events of the incident.

Sorry to correct you but ATSB does investigate RAA or any accidents it wants too or directed as in the Old Bar accident ( no fatality) and what you and other people interested in investigation outcomes is the fact that people interviewed by ATSB are not allowed to discuss this after interviews as they must sign a statement. Accident reports are in the Air saftey magazine and on the ATSB website.

 

The problem I see is that in the case of a witness seeing or involved some way with an accident as I was, then this person can not speak or write about this accident with others including other organiztions such as CASA, RAA , HGFA or here. Just saying.

 

 

[turboplanner]

Mardy said he was having trouble getting his head around the principle. Yes ATSB can step in, and they can decide not to bother with a fatal GA accident, as they've done with top rated aerobatic pilots, RAA can assist police......but all that just blurs the picture.

 

 

[Powerin]

The ATSB, with its limited resources, only investigates incidents that have the greatest safety outcome, mainly for the general public. So they tend not to investigate any RAA incidents and some GA incidents that are inherently high risk such as those involving aerobatics.

 

My guess is that the Old Bar incident did have the potential to impact on quite a few of the general public and so was investigated. An incident involving somebody practising aerobatics (GA) out in a training area will probably not be investigated, but an aerobatic incident at an air show probably will.

 

As RA flyers we can only carry on passenger, we're not allowed in controlled airspace, and we fly very low weight aircraft so the risk to the general public is perceived as lower...therefore investigations are left up to the police/coroner who are legally required (I think?) to investigate any death.

 

 

[Keenaviator]

The ATSB, with its limited resources, only investigates incidents that have the greatest safety outcome, mainly for the general public. So they tend not to investigate any RAA incidents and some GA incidents that are inherently high risk such as those involving aerobatics.My guess is that the Old Bar incident did have the potential to impact on quite a few of the general public and so was investigated. An incident involving somebody practising aerobatics (GA) out in a training area will probably not be investigated, but an aerobatic incident at an air show probably will.

 

As RA flyers we can only carry on passenger, we're not allowed in controlled airspace, and we fly very low weight aircraft so the risk to the general public is perceived as lower...therefore investigations are left up to the police/coroner who are legally required (I think?) to investigate any death.

Correct-

 

If the ATSB decides an accident does not fit the criteria for them to conduct the investigation then police are directed do do so on behalf of the Coroner (fatal accidents).

 

The police prepare an inquest brief which contains statements from witnesses and 'expert witnesses', accident scene diagrams, photos and whatever else that will help the Coroner make a finding.

 

If there is a weakness in procedures, design issues etc which played a part in the accident, the Coroner will include recommendations in his finding.

 

Hope this helps clear things up.

 

 

[Bandit12]

The hardest thing when you are on the sidelines and feel like it was "one of your own" is that sense that a reason why is so slow in coming or in some occasions will never come. This is discussed after every accident here and we get so little information. And so the frustration continues.

 

 

[Teckair]

The ATSB, with its limited resources, only investigates incidents that have the greatest safety outcome, mainly for the general public. So they tend not to investigate any RAA incidents and some GA incidents that are inherently high risk such as those involving aerobatics.My guess is that the Old Bar incident did have the potential to impact on quite a few of the general public and so was investigated. An incident involving somebody practising aerobatics (GA) out in a training area will probably not be investigated, but an aerobatic incident at an air show probably will.

 

As RA flyers we can only carry on passenger, we're not allowed in controlled airspace, and we fly very low weight aircraft so the risk to the general public is perceived as lower...therefore investigations are left up to the police/coroner who are legally required (I think?) to investigate any death.

I think most of us understand that is what currently happens but what is not understood is why the result of the investigation that does happen is kept secret. To me this is stupid beyond belief, this is a very important safety issue that is being denied RA pilots and their families for no good reason other than, 'oh that's just the way we like to do things'. How difficult would it be to have accident investigation results included in the members magazine package but separate to the magazine? or sent to flying schools?

 

 

[eightyknots]

Knowing how meticulous David was and the preparation that went into this flight, the fact that the planning and flight was executed in tandem with his CFI and how eminently qualified his CFI was, I am certain this accident will not be one of human error on David's part.The aircraft appears to have arrived at extremely high speed in an almost vertical plane and has been completely destroyed by fire.

 

For my way of thinking the cause is likely to have been one of three possibilities (and please forgive my speculation).

 

1. Catastrophic medical incident (David was almost 59), this could happen to any of us, and there is little we can do about it if undiagnosed.

 

2. Catastrophic structural failure.

 

3. Fire in flight that destroyed the wing.

 

Peter will no doubt be able to provide information if he saw David go in. I feel terribly for Peter under these circumstances, it must have been traumatic to the extreme to watch your friend go in and know he could not possibly have survived.

I keep thinking about Peter. It must have been terrible to watch: you become so powerless in such a situation. I hope Peter is OK.

 

 

[Guest Howard Hughes]

CASA is not involved in investigating accidentsThe ATSB (Federal Government) investigates GA accidents and their investigations are made public.

 

The ATSB does not investigate RA accidents; they are investigated by Police.

From an ATSB investigator about 12 months ago: "the ATSB have enough funding to investigate only 100 aircraft accidents/incidents per year, the rest are investigated by CASA and/or State police".

This is why the ATSB tend to concentrate on the most 'sensitive' accidents/incidents!

 

CASA do investigate aircraft accidents and in my opinion this needs to be reviewed, in fact they investigate more than the ATSB. You don't need to know much about 'systemic safety' to realise why this is not a good situation.

 

 

[turboplanner]

What a dog's breakfast!

 

 

[kaz3g]

....CASA do investigate aircraft accidents and in my opinion this needs to be reviewed, in fact they investigate more than the ATSB. You don't need to know much about 'systemic safety' to realise why this is not a good situation.

The ATSB looks at an aviation accident to determine why it occurred. CASA looks at an aviation accident to determine who should be blamed. CASA is the policeman and often also judge and jury.

 

CASA is a regulator and it's functions we're deliberately made separate from those handed to the ATSB when the former department was split. It was formulated to police safety and given extraordinary powers under the Act to do this including proceeding against suspected offenders by administrative action which can take away people's licences and their living without any offence ever being proven.

 

When pursuing administrative action, the investigator does not even have to have "reasonable grounds" that an offence has been committed; all that is required is a belief that a safety breach may have occurred. That breach may not necessarily even be a proscribed activity, it may just be a failure to comply with policy.

 

I strongly endorse the safety ethos, I support the prosecution of serious offences in the courts, but I have an inherent distrust of administrative actions that are almost unable to be countered because Tribunals take into account those same safety policies to protect themselves and are not prepared to depart from the CASA line. The courts can only review such decisions on a question of law whereas it is the merits that need looking at.

 

Remember, in an administrative action, all that needs to be demonstrated is that, on the balance, it is more probable than not that a safety breach may have occurred. In the prosecution of an offence, the criminal standard of beyond reasonable doubt applies.

 

Kaz

 

 

[David Isaac]

Thanks Kaz, that explains a lot, and ... that cost us nothing ... LOL

 

 

[Guest Howard Hughes]

CASA is a regulator and it's functions we're deliberately made separate from those handed to the ATSB when the former department was split. It was formulated to police safety and given extraordinary powers under the Act to do this including proceeding against suspected offenders by administrative action which can take away people's licences and their living without any offence ever being proven.

And separate they should be!

The ATSB should have jurisdiction over (and be funded for) all aviation accidents/incidents. People are asking for answers with regard to RAA accidents, we are not going to get them unless the ATSB is given the resources investigate the causes of all accidents. The regulatory review and investigations should run concurrently (and separately).

 

From the safety investigations, recommendations should be made to the regulator regarding any possible procedural changes arising from the investigations. This along with the coroners recommendations acting as the 'peer review' part of the process.

 

 

[Guest Maj Millard]

One may hope that Peter didn't see the crash at all, he would have seen the aftermarth of course, but if he was ahead of David at the time, it may all have happened behind him.................................................................Maj...

 

 

[David Isaac]

One may hope that Peter didn't see the crash at all, he would have seen the aftermarth of course, but if he was ahead of David at the time, it may all have happened behind him.................................................................Maj...

Ross,

Peter was in fact half a mile in front of David, but did see the whole event due to unusual circumstances. I have given a brief summary of Peter's account on the 'Ultralight Crash near Temora' thread.