Fatal Trike crash Girrwaween, NT 27/10/13

[turboplanner]

It's not often we find a Coroner's report, but I was doing some searching and found this one:

 

PARTIES: –––––

 

 

[ClintonB]

We could all take away from this that rules and regulations are there to be adhered to for our own benefit. A few individual mistakes or deviation from how we are taught to do things compiled together had this terrible result-which when reading who would want to put their family and friends through.

 

 

[Riley]

I think perhaps, the long-laboured-on veracity of the statements uttered by the vendor of the trike brings a 'not-relevant-to-the-accident' content to the coroner's report. Ultimately she decreed that the bodgy history (known to the purchaser) had no bearing on the final unfortunate result.

 

 

[M61A1]

We could all take away from this that rules and regulations are there to be adhered to for our own benefit. A few individual mistakes or deviation from how we are taught to do things compiled together had this terrible result-which when reading who would want to put their family and friends through.

Yet , I suspect that if he had done the same thing at 1000' in the middle of nowhere (obeyed the rules, but ignored the laws of physics), the result would have been the same.

 

 

[Callahan]

Read it all. All that for an Ultralight crash? Sounds like they're trying to convict a man who seemed perfectly legal & sane to me. He messed up the wing, fixed it. End of story.

 

I knew you Aussies were burdened with excessive rules & regulations but that long winded pile of horseshit by attorneys & bureaucrats who don't know shit from beans about ultralights or aviation but looking to prosecute somebody in general..... was rediculous.

 

If the guy is guilty of anything it's the fact that he should've given the victim more training with the 912. And why all the delving into the victims personal life history which had nothing whatsoever to do with the crash?

 

 

[turboplanner]

Read it all. All that for an Ultralight crash? Sounds like they're trying to convict a man who seemed perfectly legal & sane to me. He messed up the wing, fixed it. End of story.I knew you Aussies were burdened with excessive rules & regulations but that long winded pile of horseshit by attorneys & bureaucrats who don't know **** from beans about ultralights or aviation but looking to prosecute somebody in general..... was rediculous.

 

If the guy is guilty of anything it's the fact that he should've given the victim more training with the 912. And why all the delving into the victims personal life history which had nothing whatsoever to do with the crash?

I see you've got a winner Callahan; this is not an NTSB report, nor an ATSB report, it's a Coroner's report into the death of a person not the crash of an aircraft. So there's personal information there for the family, and it's rare for a Coroner to do much more than mention that the cause of death was a broken neck, which occurred after a plane fell out of the sky. This was a good one with a lot more detail.

 

 

[turboplanner]

Yet , I suspect that if he had done the same thing at 1000' in the middle of nowhere (obeyed the rules, but ignored the laws of physics), the result would have been the same.

How would he know the laws of physics for that wing and that trike?

He bought the thing, probably because his friend was able to demonstrate a faster aircraft and tighter turns.

 

He was a Plant Operator - Excavator, in the earthmoving business.

 

Where was the administrative responsibilty for these two people, where was the instructor to take this person up to a safe altitude and train him on the new wing?

 

By flying below 500 feet the police could have charged him with culpable negligence if he had killed a passenger, and his estate still could be sued if his death has disadvantaged someone.

 

 

[Downunder]

As I read it, the deceased had not flown ANYTHING in the 18 months prior, and that last flight was a BFR.

 

Then he gets in a totally unfamiliar aircraft solo and starts low level manouvers on the first flight....FFS....

 

The repeated references to his character do nothing to change the facts about his stupid decision making....( but might make the family feel better?)

 

I don't really understand the witch hunt with the gopro. Finding it didn't change much but fed the lawyers and police ego....

 

Bet the bloke regrets sending it in......

 

 

[facthunter]

It had relevance to his reliability as a witness. A "sworn" statement should have some meaning generally but it does at law for sure.. Perjury is a crime but not in the Par liar ment where privilege overides it.. Wilfully and knowingly telling a lie. Never happens in Newspapers eh? Under oath is significant , but then all our polies swore to "serve" the country , maybe in the animal husbandry sense? Nev

 

 

[w3stie]

Remind me never to tell porky pies to a Coroner :)

 

 

[facthunter]

The "beat up near the house ", syndrome, has a long history of bad outcomes, tragically usually witnessed by family. (as is the nature of the event). The trauma must be extreme.. It's done near aero club s too but hopefully less often than once was the case. Nev.

 

 

[M61A1]

How would he know the laws of physics for that wing and that trike?He bought the thing, probably because his friend was able to demonstrate a faster aircraft and tighter turns.

He was a Plant Operator - Excavator, in the earthmoving business.

 

Where was the administrative responsibilty for these two people, where was the instructor to take this person up to a safe altitude and train him on the new wing?

 

By flying below 500 feet the police could have charged him with culpable negligence if he had killed a passenger, and his estate still could be sued if his death has disadvantaged someone.

And that....is the stupidity of our wonderful system, at 501' it's all good, when the reality is, it's more than likely the outcome would be the same.

He was a PILOT.

 

The laws we make cannot ensure adherence to the laws of physics, but if you are going to remain alive, it's best that you acquaint yourself with the basics.

 

 

[M61A1]

I see you've got a winner Callahan; this is not an NTSB report, nor an ATSB report, it's a Coroner's report into the death of a person not the crash of an aircraft. So there's personal information there for the family, and it's rare for a Coroner to do much more than mention that the cause of death was a broken neck, which occurred after a plane fell out of the sky. This was a good one with a lot more detail.

Exactly, we know how he died, and why, it's a massive waste of public money for no gain at all.

Then some people who make the rules turn around and claim that every death costs X dollars. ICB, they don't have to spend the money, and especially when there's nothing to gain.

 

 

[turboplanner]

So you can see that even a Coroners report can show administrators where the weaknesses are in knowledge and training, how to improve standards and supervision, and where to focus compliance and enforcement.

 

 

[M61A1]

It's certainly possible, that on occasion they can reveal useful information, but that one was a waste of public funds. It was actually the best possible outcome, one person screwed up and only that person payed the price. Stop throwing good money after bad.

 

I have made a point of chasing up various coroner's reports for quite a few incidents (some aircraft, some automotive), and I would have to say that for the most part they are an incredible waste of resources for what little and occasionally useful information they reveal.

 

Although, that one was probably the least biased one that I have read, quite a few of them just seem to be a "witch pursuit thingy" (SouthPark reference), where they choose who to blame rather than detemine actual cause.

 

 

[turboplanner]

It's certainly possible, that on occasion they can reveal useful information, but that one was a waste of public funds. It was actually the best possible outcome, one person screwed up and only that person payed the price. Stop throwing good money after bad.I have made a point of chasing up various coroner's reports for quite a few incidents (some aircraft, some automotive), and I would have to say that for the most part they are an incredible waste of resources for what little and occasionally useful information they reveal.

Although, that one was probably the least biased one that I have read, quite a few of them just seem to be a "witch pursuit thingy" (SouthPark reference), where they choose who to blame rather than detemine actual cause.

Well I'll give you three guesses as to how much luck you'll have convincing every government in Australia to give up the position of Coroner, citing "waste of money".

 

 

[M61A1]

I don't need three. It would be nice however, if they were a little more discerning about which cases they actually spend our money on.

 

 

[old man emu]

You clearly don't understand the role of the Coroner in the Judicial System.

 

A lot of what was printed in that report was pro forma for a Coroner's report. That was all the stuff about the identificaton, ancestry, time , place and date of death, cause of death. If you could get a copy of the deceased's Death Certificate, you would find that there things are included in the record. That also included details of children and his marital and employment status.

 

Another duty of the Coroner is to determine if the actions or inactions any person or persons caused the death, and to recommend that if another hand was involved in the death, should the matter be reviewed for criminal prosecution. Clearly that was the reason for the questions about the prior accident history of the aircraft, and why the previous owner was interrogated about his porkies.

 

It is clear that the Coroner came to the conclusion that the previous owner was a scared dickhead trying to cover his arse, but the he did not contribute to the death.

 

The Coroner seems to have come to a correct conclusion that the deceased was solely responsible for his own demise due to unfamiliarity with the performance of the aircraft. The performance he did not know about was the lift capacity of the wing and the torque effect of the engine being in the opposite direction to that which he was used to. Would the result have been any different if the manoeuvre had been initiated at 500 ft or higher. I'll leave that to someone experienced in spin recovery in trikes, but I doubt the answer would be 'No'.

 

 

[M61A1]

And what did we get out of the report that wasn't already obvious?

 

I'm certain there are times an inquest is of great importance, but it seems that we spend a lot of Joe Public's money to have someone point out the obvious and at times to proportion blame to anyone but the those actually responsible.

 

 

[Head in the clouds]

How would he know the laws of physics for that wing and that trike?He bought the thing, probably because his friend was able to demonstrate a faster aircraft and tighter turns.

He was a Plant Operator - Excavator, in the earthmoving business.

 

Where was the administrative responsibilty for these two people, where was the instructor to take this person up to a safe altitude and train him on the new wing?

 

By flying below 500 feet the police could have charged him with culpable negligence if he had killed a passenger, and his estate still could be sued if his death has disadvantaged someone.

With the greatest respect turbo ... you've clearly not spent much time in the NT have you?

 

SM Greg Cavanagh is well known, in fact Cavanagh St in central Dwn is apparently part of his family name, such uninterrupted longevity they have up there. I'm astounded to see he's still an SM, you'd have thought he'd have made it to circuit judge at least ... In my experience he had to be one of the driest and least prone to general worldliness that I have ever come across - no disrespect intended to the judiciary in general. Considering the relative 'wildness' of the NT it astounded me, and others, just how isolated from reality the Territory Courts proved to be, one would think they might be more down-to-earth than in other places, but in my experience the opposite was the case.

 

The consequence of which is the complete disregard often shown by everyone, including supposedly responsible helicopter pilots, for the police (telling them porkies after a fatality, assuming they'd get away with it) and the judiciary. People in the East think it's bad in Townsville with adolescent indigenous as young as seven running around drunk, drugged and armed all night, blatantly stealing from houses, stealing cars, some with 160 offences before they reach teen years, but you should see the shadier spots of Darwin, and then wonder why places like the Don Dale detention centre became what they did without particular notice being paid by anyone up to and including the Ministers responsible.

 

 

[turboplanner]

And what did we get out of the report that wasn't already obvious?I'm certain there are times an inquest is of great importance, but it seems that we spend a lot of Joe Public's money to have someone point out the obvious and at times to proportion blame to anyone but the those actually responsible.

Firstly you got a report; If I hadn't found it you'd be complaining about something else. Secondly there are MANY trike pilots for which this would be enough warning to save their lives; and the powered parachute guys who've been fitting high performance chutes, or thinking about it will now have the wing change packed into their safety tool boxes; others will be remembering the lesson of prop rotation; a multi millionaire in NZ nearly killed himself in a different Spitfire by not being alert to the torque reverse; and I can think of at least one other who jumped in an aircraft with a lower performance wing, and put the aircraft into the ground.

 

 

[turboplanner]

With the greatest respect turbo ... you've clearly not spent much time in the NT have you?SM Greg Cavanagh is well known, in fact Cavanagh St in central Dwn is apparently part of his family name, such uninterrupted longevity they have up there. I'm astounded to see he's still an SM, you'd have thought he'd have made it to circuit judge at least ... In my experience he had to be one of the driest and least prone to general worldliness that I have ever come across - no disrespect intended to the judiciary in general. Considering the relative 'wildness' of the NT it astounded me, and others, just how isolated from reality the Territory Courts proved to be, one would think they might be more down-to-earth than in other places, but in my experience the opposite was the case.

 

The consequence of which is the complete disregard often shown by everyone, including supposedly responsible helicopter pilots, for the police (telling them porkies after a fatality, assuming they'd get away with it) and the judiciary. People in the East think it's bad in Townsville with adolescent indigenous as young as seven running around drunk, drugged and armed all night, blatantly stealing from houses, stealing cars, some with 160 offences before they reach teen years, but you should see the shadier spots of Darwin, and then wonder why places like the Don Dale detention centre became what they did without particular notice being paid by anyone up to and including the Ministers responsible.

Three weeks driving around. Oh and watching NT Cops.

 

 

[onetrack]

Any death involving suspicion, or any unnatural or unexpected death, where it is possible others were involved, is called a "reportable death", and must be reported to the coroner.

 

It is then up to the coroner to decide whether there are valid reasons for holding an inquest. The whole scenario surrounding this crash was murky, and called for investigation.

 

Coroner and inquests - NT.GOV.AU

 

The inquest cleared the air and found the deceased pilot solely responsible for his own death through his careless and ignorant approach to flying an unfamiliar aircraft. He should have known better, given the fact he'd had a degree of training.

 

The basic problem lies in whether any other gung-ho, ignorant, arrogant, brash would-be pilot, would ever read this report, and take note of it, and exercise caution accordingly.

 

Methinks not - the cemeteries contain plenty of this type of personality who eventually killed themselves because of their arrogance, their "know-it-all" attitude, and their risk-taking behaviour.

 

The problem lies in identifying them and taking positive steps to try and stop them from killing themselves - and other innocents.

 

All the aviation regulations and enforcement in the world still doesn't stop dozens of these people from killing themselves every year.

 

 

[Head in the clouds]

Any death involving suspicion, or any unnatural or unexpected death, where it is possible others were involved, is called a "reportable death", and must be reported to the coroner.It is then up to the coroner to decide whether there are valid reasons for holding an inquest. The whole scenario surrounding this crash was murky, and called for investigation.

Coroner and inquests - NT.GOV.AU

 

The inquest cleared the air and found the deceased pilot solely responsible for his own death through his careless and ignorant approach to flying an unfamiliar aircraft. He should have known better, given the fact he'd had a degree of training.

 

The basic problem lies in whether any other gung-ho, ignorant, arrogant, brash would-be pilot, would ever read this report, and take note of it, and exercise caution accordingly.

 

Methinks not - the cemeteries contain plenty of this type of personality who eventually killed themselves because of their arrogance, their "know-it-all" attitude, and their risk-taking behaviour.

 

The problem lies in identifying them and taking positive steps to try and stop them from killing themselves - and other innocents.

 

All the aviation regulations and enforcement in the world still doesn't stop dozens of these people from killing themselves every year.

All quite true, and as a result of this discussion just maybe some one will read the report and learn something that may save them from making the same mistakes. Nev pointed out the crux - how many similar crashes have there been over peoples' own property, their friends' parties or public gatherings they're attending, from the low level 'look at me' beat up with a low-level turn, collision with trees or power-lines, stall in the turn from skidding, turning down-wind or whatever, mostly by people with no low-level training at all, thus having no understanding of the illusions created from ground-related flight.

 

If it (discussions like this) saves one life then that's a start, hopefully in time FT establishments might have a library of compulsory viewing/reading as part of the pilot certificate, rather than relying on the chance of newbies coming across it on a forum.

 

 

[M61A1]

While I am all for the relevant people being able to access relevant information that may prevent their untimely demise, coroner's reports are not generally publicised, and at time's a bit of digging is necessary to find them.

 

Just suppose that the actual experts who investigated some of these incidents were able to release the actual cause, without having to go through weeks, and sometimes months of expensive legal proceedings to establish what is often a "no-brainer".

 

1. The necessary people would get good information in a timely manner.

 

2. Heaps of taxpayers money not spent on finding out the obvious.

 

Sure there will still be lots of times an inquest is necessary, but there are a lot that could easily bypassed.

 

Some of the ones I have seen, arrive at pretty wild conclusions considering the evidence put in front of them, and some of these conclusions seem to be more about social justice (blaming someone else) rather than actual useful information for prevention of re-occurrence.