Coroners Recommendations

[Guest drizzt1978]

Well guys, I partially agree with some of the things the coroner suggests, RA AUS should have the power to yank an aircraft or certicate (licence) from certain individuals. Especially Idiots selling aircraft that havent ticked all the boxes!! I have always wondered, what happens If joe Blow flys upside down over the airstrip, (just an example)

 

RA AUS should have some serious funding and the ability to enforce its rules and regulations, especially given the rate at which we are growing. CASA has the death rate, and one day we will be as big as them, Best to build a platform that can be grown on, and not get too big and have problems.....

 

My 2 cents

 

Michael

 

 

[turboplanner]

This is a rather puzzling report in two areas:

 

1. The "unacceptable level of fatalities among Ultralight users" comment would appear to be clearly incorrect in fact, and since recommendations of the tightening up type, in my opinion flow from it, if I was CASA I wouldn't weight that heavily.

 

2. Two sequences took place, not one:

 

(a) the engine failed, something which can happen in RAA, GA or even on the Hudson. That was the cause of an emergency requiring a forced landing.

 

(b) at that point the aircraft was flying dead stick, and it seemed to me there was one suggestion that it started the gliding sequence at over 4000 feet.

 

Again, this can happen in RAA and GA.

 

In my opinion the cause of the deaths was failure to complete a successful forced landing, and that could have gone down the Pilot action path, mechanical path, or other.

 

So again, my opinion is that experienced CASA people may not place too much weighting on the report.

 

We are self regulating, which means that when an accident happens which we are involved in by being part of designing, building, testing, maintaining and operating a product, we have a Duty of Care to ensure no one is hurt.

 

If we don't exercise out Duty of Care, for example if we forget to tighten the nuts after we change a wheel and someone is injured or killed, under self regulation we will be compensating that person, who if made a quadriplegic will get about $6 million, and if we knew the nuts were loose, or we sold a product with loose nuts, then if they caused the accident we will spend around 6.5 years in prison.

 

So that's a much stronger disincentive than the pre 1980's licence suspension of hundred dollar fine.

 

If the Government, as some suggest, might want to take over and check each aircraft, ticking off each item, and they missed some nuts, they would assume the public liability, and that's why you don't see them rushing back to inspections where they have to OK something.

 

Under self regulation the people who derive the profit or enjoyment pay the penalty if they don't discharge their duty of care, which seems fair to me.

 

There will be a transcript of proceedings somewhere, and that could shed some light on the direction the Coroner took in coming to these conculsions.

 

As to the engine, I would be very wary about speculating what was wrong with it or who knew about it.

 

Finally, I'm not a lawyer, just been involved with a few of these cases, but if you've designed any part of an aircraft, built or helped to build, tested, or own an aircraft, or if you are not really familiar with public liability and negligence cases, I would very strongly recommend you spend the $150 or whatever and get an explanation from a lawyer who is a public liability or negligence specialist. I think if every member was to do that there wouldn't be too many issues about record keeping and safety actions for a long long time.

 

 

[68volksy]

I don't think anyone would argue that the cause of the accident is due to many factors. You will read in the report that no blame can be layed on any one incidence.

 

It's the other side of what the Coroner uncovered that is vastly worrying. The fact that the rules and regulations that Recreational Aviation told the government, pilots and the public were put in place have never been enforced.

 

What's the point of putting the rules in place, rules that every member of this society relies upon, if no-one ever checks they are being followed.

 

For my mind I would rather just plaster over every aircraft in massive lettering "Fly at own risk. Assess all previous aircraft owners skill, honesty and diligence before entering". At least no-one would ever be blamed for not telling it how it is.

 

 

[turboplanner]

Volksy - sign: it's there in RAA aircraft for the purpose you suggest.

 

Similarly you'll often see signs warning about hazardous operations - even wet footpaths. You Duty of Care includes warning people (but you still have to ensure they can't be hurt - it just that the costs are greater if you didn't warn them). Ansett Airlines had the best one I've seen on their baggage trucks "passengers only permitted to ride on seats"; there was only one seat.

 

Rules

 

A non compliance needs to be uncovered before the Rule can be enforced. If someone knows a rule is being breached but still does something, it's probable to be charged with Manslaughter if a death occurs. Talk to a lawyer Volksy.

 

 

[facthunter]

Coronial inquests.

 

One of the problems with these types of enquiry, is that the "judge" is not expert in matters aviation, and may draw conclusions that while "true" are not actually causal of the accident.

 

Material that I have read elsewhere on the condition of the engine, would lead me to consider that due to some occurrence, (possibly a high power sudden stoppage) the engine front web, (a press fit with an extension of the front journal) shifted and became misaligned, thus causing vibrations and loads, that caused the front web to fail, ultimately..

 

How this could be detected in normal inspections is beyond me. The vibration may have been an indicator, and unless accounted for should be investigated, possibly by a complete strip of the engine. I am not trying to be clever in retrospect here.

 

This was a catastrophic failure of the engine, which is fairly rare in Rotax 4-cyl engines. I don't understand where the statement that Rotax engines are not certified, because they are prone to sudden stoppages, can stand scrutiny.

 

We are all trained in engine outs, whether in multi-engine or single engine aircraft, and because the situation in a single engine is that the landing, which is immediately needed and truly forced has an element of luck as to the terrain available, and what options are available to manoeuvre, the outcome is never guaranteed.

 

The relating of the altimeter reading to the engine failure is drawing a long bow, and I would give that likelihood no credibility whatever. The only severe force applied to the aircraft was on violent contact with the ground, and the instrument could be jolted and jammed anywhere.

 

Unfortunately a lot of this has implications for RAAus whether justified or not, and I hope the findings are interpreted by wise men.

 

I find this report disappointing, in that I don't feel that it really hits the spot. There are significant incorrect statements in it. Many questions still unanswered, and probably never will be. Nev

 

 

[Guest pelorus32]

I've thought about this a great deal since reading the report. I find the report deeply disappointing and unsatisfactory. In saying that I mean no disrespect to the Coroner who had to wade through large amounts of evidence and make sense of it all.

 

My dissatisfaction arises as follows:

 

1. I heard about this accident within an hour or so of its occurence. At that point I had the basic facts: a Sting had suffered an engine failure and during the subsequent forced landing both occupants were killed. And also during that sequence the BRS was triggered;
    
    
   
2. Within a very short space of time afterwards - I think within 24 hours but I could be mistaken - I heard reliably that the crankshaft had failed causing the engine failure.
    
    
   

 

 

In that I'm sure I was no different to most active RAA pilots. Subsequent to that we wait months for this report only to find that the key questions - really the only questions that matter have not been answered. Those questions are:

 

1. Why is it that two men died as a result of an engine failure? We all train regularly for this event and the evidence seems to suggest that they were not particularly height constrained. So why did a run of the mill engine failure cause the death of two people? They are not supposed to and many members of this forum have lived through such an event. What caused this engine failure to become a double fatality and what role did the BRS play? This report provided no answers to those questions and indeed the report appeared factually weak, uncertain and soft in the area that dealt briefly with those questions;
    
    
   
2. What caused the crankshaft to fail? The report describes the mode of failure but makes virtually no headway with respect to the reasons for failure. Nev tells me substantially more than the report - and that's not belittling Nev's input.
    
    
   

 

 

The Coroner states that her role is to help prevent such events occurring again. However in her own report she acknowledges that the links between the matters on which she does make findings - record keeping etc - and the engine failure cannot be made!

 

Further there is a passing comment with respect to the fitting of a MAP gauge but no explanatory text.

 

I fail to see how this report advances safety particularly when the Coroner herself can find no link between the accident and the matters which dominate her findings.

 

In saying what I say people should not make assumptions about what I may think about dodgy record keeping etc.

 

Regards

 

Mike

 

 

[BLA82]

Unfortunately it takes one bad apple to make it worse for all.I will be making an editorial comment on this soon including copies of newspaper reports, and other activities of Mr Coates including attempts of Blackmail, emails that have brought my wife to tears, using 3rd parties to send offensive emails, distributing people's email addresses to others and disgusting emails sent by Chris Seimers

 

I personally hope that the RAAus kick these people out of our Association and as Lee Ungerman says - what we do today paves the way for our freedoms of tomorrow - unfortunately in this case Coates has provided cause for our freedoms to be reduced whilst placing a huge burden on us all.

 

Remember this when touching an XCOM radio or an X-Air aircraft or an MCP Product

How pathetic are these people, I to would like to see RA AUS give them the boot and as far as the emails that upset your family, Ian I hope you realise that for every:censored: who does this there is a thousand of us who appreciate what you do and thanks to your wife for supporting you:clap:

 

I hope Mr Coates products are given a wide birth:off topic:

 

 

[robinsm]

Just my 2c worth. I have an Xair that has an Xcom radio installed. Notwithstanding the feelings about Mr Coates expressed above, the aircraft and the radio stand on their own feet and I have had much pleasure out of them. Knock the person, not the products please. We went to war with Germany but we drive mercedes.

 

 

[BLA82]

Knock the person, not the products please. .

Fair Point but seek alternative suppliers I think the manufacturers of these products should look at who is importing their products and seek alternatives. I wouldn't buy a can of coke of Coates on princible

 

 

[motzartmerv]

Mike, thats a good point ( a few good ones actually).. the report really danced around the big issues.. Exactly what happend to the BRS.. all she said was it probably fired during the crash... how was this determined, ??..

 

The report says they (pilot) did evry thing right, good paddock, into wind, uphill.. what went wrong..was it a stall spin??.. glide to short?? impact on overun?? impact on undershoot??..

 

I realise alot is difficult to assertain..

 

Was the fireing handle activated??.. not sure how these things work.. how are they triggered??..

 

 

[Guest ozzie]

His radios are now manufactured offshore in the USA.i think it is with Narco.

 

 

[Guest Maj Millard]

For what it is worth, I was involved with a double fatality accident in California years ago. Without going into total details, the low -time wealthy pilot bought a very slick new aircraft, put his mate in it, lost it, and probabily flat spun onto a hill.

 

On examining the wreckage it was found that the balistic chute had deployed, and was strung out straight, to one side of the aircraft.

 

It was determined that the chute had deployed at impact, due to the close proximity of certain items that are liberated during deployment, plus the fact that the deployment handle was still firmly stowed. The parachute canopy was still in a folded condition, indicating any lack of deployment.

 

 

[rick-p]

I've read it and all I can say is in my 25yrs in the legal profession I have never read so much crap based almost totally on conjecture and miss information.

 

What happend to the good old facts and circumstances rule.

 

Unfortunantely the rules of evidence basically don't apply to a Coronial inquest and if the Coroner see's fit any submission maybe admitted.

 

It's almost as though the players were involved in a witch hunt to apease the poor families of the victims but why make us all victims for the sake of a knee jerk reaction to a very sad and unfortunate happening.

 

I think as we get older we have a tendancy to tolerate fools less and less and we now know where all the fools work.

 

Freedom of speach remember they have spoken and now have I.

 

Rick-p

 

 

[rick-p]

Postscipt!

 

Nev you are just too damn polite.

 

 

[turboplanner]

RICK-P the Coroner did seem to be alluding to the evidence she received as setting up for the civil suit.

 

What would be very enlightening to us is to be able to read the RAA crash investigation report.

 

 

[Guest keeffe]

Yeah I agree the report seemed to be written by a mis informed person. She at one stage dismisses one of two Professional metal fatigue specialist because she feels one is more credible than the other. Shes a lawyer not a mechanic, try and get her to change her own car oil and see how she goes. Someone out of the know shouldn't make these asumptiions.

 

It does not outline anything. She's jumping up and down over record keeping and so forth, put that record keeping aside 100 hours who's to say that the new owners did not thrash the machine. Thats is hard to prove and really it is fair to say that the damage may have occurred with the new owners, after 100 hours of flying who can say.

 

All these things are cost blowing. For instance national aircraft register, these goes no landing fees.

 

Sigh I hope our great body the RAA, meet this at a head.

 

Mike

 

 

[Guest keeffe]

Another thing, if mr Coates is willing to say records were made up, surely he would admit why the weights were on the prop there was no finding as to why or how they got there in the firs place.

 

This is a half assed report totally apalling

 

Mike

 

 

[Guest Juliette Lima]

Mike, thats a good point ( a few good ones actually).. the report really danced around the big issues.. Exactly what happend to the BRS.. all she said was it probably fired during the crash... how was this determined, ??.. The report says they (pilot) did evry thing right, good paddock, into wind, uphill.. what went wrong..was it a stall spin??.. glide to short?? impact on overun?? impact on undershoot??..

I realise alot is difficult to assertain..

 

Was the fireing handle activated??.. not sure how these things work.. how are they triggered??..[/quote

 

Perhaps if a number of expert witness' including those from RAaus could not provide answers for the coroner to make definitive findingsabout factors influencing the final phases of the flight, then it is possible these questions may never be answered.

 

JL

[68volksy]

You guys want it all. First of all there is the very strong (and seemingly justified) call for no more rules and regulations in order to keep costs down. Then this is followed by slamming the only investigation that will be afforded the accident and calling it lax in many areas.

 

From the way I see it this is all the investigation that will occur as this is all the money that we are willing to pay. You get what you pay for. The alternative is either paying more for full ATSB-like investigations or asking the Coroner not to investigate deaths. If all that RaAus and its members asks for is one inexperienced Coroner to look into the accident and determine how and why it occurred then this is all that we will get.

 

What is most scary is how many questions the process raised and how many remain unanswerable by the current requirements of RaAus. From my two cents we have to accept this and make it perfectly clear to the public (and the Coroner) that this is what we want in order to keep costs down. The other option is moving into a tighter regulatory system.

 

Turboplanner - I agree that the laws are already in place and the stickers already exist. What I would like answered is why the Coroner simply didn't state "They flew this plane at their own risk and in line with the current requirements. End of report." From what I see she didn't tie it up in this manner because she did not see that as an acceptable solution to the general public.

 

 

[turboplanner]

Volksy, there are two separate subjects:

 

1. An Accident Investigation, which is carried out by RAA. I haven't seen one, and I'm not sure where they are published, but they should be on the Web like the CASA report so we can all learn from them, and throw in our ten cents worth afterwards.

 

2. A Coroner's hearing. THIS IS NOT THE ACCIDENT INVESTIGATION, and we don't have any option on whether the Coroner decides to make enquiries or not - it's an automatic process. If you choked on a peanut at a restaurant, the Coroner will investigate the cause of your death. In an ideal world, the Coroner, usually a Magistrate with a long legal background would call for a copy of any investigation report and take evidence from relevant people, then sift though the truths of the matter.

 

Re "they flew the plane at their own risk" I need to be careful here, but I'm talkinging about Speedway, not some other form of Motorsport, and these two cases explain the intricacies.

 

Case 1

 

A country club organised a race meeting, a volunteer placed ads, made up fliers, typed up the Programme, a spectator was injured by flying dirt, and sued the Club for damages (perhaps $40,000)

 

The Club defence was that motor racing was dangerous, and flying dirt was part of it. They lost the case when the plaintiff's lawyers pointed out that if that was the case they should have had a warning on the ticket or the Programme (the Wet Pavement warning), and in fact had advertised the race meeting as a family event, implying it was safe for a family to attend.

 

CASE 2 (On a track which had the above warning on the Programme)

 

Some years ago a kid was injured by a flying car. The Promoter was distraught and visited the kid in hospital, paid the medical expenses, did all he could for the family etc.

 

A couple of years later the father was sitting round the table with some friends when the subject came up. "Why didn't you sue them" asked a friend "because it said on the programme that "Motor Racing is dangerous, you enter the track at your own risk" said the father.

 

The friend said don't take any notice of that, go and see a Public Liability lawyer. He was short of money, and he did.

 

The case went on for several years, and the outcome was that it is not lawful for someone to give away their right to sue (similar situation where you are asked to "sign" that you do something at your risk.), that the accident had occurred because part of the catch fence was incorrectly attached (similar to the wrong nyloc procedure) and therefore the promoter was negligent. I think the compensation argument started at about $1 million. IN this case the fence had probably been that way through several ownerships, but Public Liability can be black and white.

 

So, after the first case, we had reminded all tracks to put the motor racing is dangerous warning on all programmes and at the track entrance, but after the seonc case we had to advise them to change it to read something like "Motor Racing is danregous and you enter the premises at your own risk, however you have the right to take legal action related to any negligence by the Promoter."

 

 

[Guest Crezzi]

Volksy, there are two separate subjects:1. An Accident Investigation, which is carried out by RAA. I haven't seen one, and I'm not sure where they are published, but they should be on the Web like the CASA report so we can all learn from them, and throw in our ten cents worth afterwards.

 

"

A few (10 !) are published here http://www.raa.asn.au/accidentreports/index.html

 

According to the same page, the reason there aren't more is that "RA-Aus believes it inappropriate to publish all investigation reports in full because they are just a repetition of the same old pilot errors."

 

I'm not sure that I'm allowed to use the word I would choose to describe this policy - suffice to say that I don't agree at all. When I flew in the UK, I learnt a huge amount from the accident reports published in a separate A5 pamphlet supplied quarterly with the BMAA magazine.

 

John

 

 

[Guest ozzie]

Skydiving is an area were lawers can have a field day. training, equipment, location ect . so now in the States when you rock up to do a tandem they verbally tell you then video record you listening to a tape telling you of the risks then signing the document.

 

on all equipment, canopies, harnesses ect a large orange information panel is sewn onto them clearly stating that the risk is death and you should NOT use the equipment for skydiving activites. there was a case were a automatic opener activated but the canopy malfunctioned so they have changed the name of these from AODs auto opening devices to AAD automatic activating devices. they will activate but not necessrily open the canopy. nowadays you just have to cut the lawers off at every turn as they will and can drive a wedge into any loophole.

 

i've tried to open or save this report on two computers but it just won't happen. anywhere else i can access this or can some one do a cut and paste and post it here.?

 

just been reading the replies about the prop strke and crank breaking. was it a propstrike or sudden engine stoppage.? balance weights. just one blade replaced. damaged hub from the strike unbalanced spinner.? or did the past or new owners just idle too low and shook the box until the crank was damaged then broke. most engines will run 20 to 50 hrs after a prop strike before showing problems. sudden stpage usually problems show up very early after. a gearbox will not really save a crank in a propstrike but a clutch will. rubber dampners in the box just ease the effect not prevent damage.

 

No amount of rules, laws or even correct by the book operation will save you from false paperwork and lies. sounds like these guys will be sued to the eyeballs. sounds like they went from the start with deception. lessons for those who work on the shonkey side. i just don't accept ths sort of person in anything i do regardless as it will allways come back at them.

 

Ozzie

 

 

[jcamp]

She at one stage dismisses one of two Professional metal fatigue specialist because she feels one is more credible than the other.Mike

I have not seen the transcript only her report and the ASTB report. Suspect both of them were trying not to be too definite as she tried to get a yes/no answer from a maybe.

 

For those who haven't seen them the points on an S/N graph look more like a shotgun pattern than the nice lines in fig xxx in a textbook.

 

 

[Guest pelorus32]

You guys want it all. First of all there is the very strong (and seemingly justified) call for no more rules and regulations in order to keep costs down. Then this is followed by slamming the only investigation that will be afforded the accident and calling it lax in many areas.

G'day Volksy,

 

My feeling is a little different. I am happy that the Coroner is the one to make the report - if that's what the organisation and its members want.

 

What I expect though is that the Coroner will do an effective job of firstly identifying what is important; secondly examining the evidence with respect to those things; and thirdly producing a clear report about what they found - and that includes being clear about where they were unable to get to the bottom of an issue due to lack of/conflicting/ambiguous information.

 

We expect our judicial officers to effectively complete such tasks - it's their bread and butter.

 

I found that this report fulfilled few if any of those requirements.

 

Regards

 

Mike

 

 

[Yenn]

It would seem that coroners are not all that high up on the credibility stakes.

 

We had a good case in Townsville not so long ago, the coroner said the policeman had caused the death of an aboriginal. The court declared him not guilty, last I heard they were going to have another coroners inquiry.