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Light plane crashes in SA's South East


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I think he's talking about the one that went into the ground at Marlborough. ATSB suggested sleep inertia was main cause. Pilot woke to go on mission, didn't go through full fuel calcs and checks due to being still half asleep and they ran low on fuel on homeward leg. Tried to land at malborough but ended up in fog while landing and lost spatial orientation. The medical urgency might have caused a rushed preflight and maybe if it was not as rushed they might have been on the ground longer so the pilot might have woken up more before he did the fuel checks. But that's somewhat speculative. The child patient was stable and the return flight when they ran low on fuel was basically a non urgent flight home.

 

The hamilton island was a cfit ( ocean) due to flying into a black night.

 

 

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Really why it worked for many years in RPT before even AUF or RAA existed in GA.

That's the problem, it didn't work so fantastically well in RPT. That's why training like crew resource management training was invented, as well as standard operating procedures designed around a 2 person crew. While it may reduce the possibility of task fixation by the PIC, and even that is a big may, it creates many other more problematic issues. Like I said, there is a very good reason casa made multi crew operations require a training course.

 

 

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TWO (or more even) could be a help IF they are integrated into a system of management that is purpose designed and understood. You can't have government of the cockpit by a large committee and you must have a known chain of command, anytime there's more than one person there. If one of them owns the plane there may be a difficulty there.

 

TWO check Captains flying together was often a hazardous operation, in the "olden" days The CM1 and CM2 concept must be agreed, known and adhered too . The operations manual specifies the actions of the PF and PNF where a two person crew are REQUIRED. Compliance with the approved Type Operations Manual is a legal requirement of any AOC a company holds.

 

Just adding another person is not enough if the position is not clarified fully as to what the relevant duties are. A conflict situation wouldn't reduce stress. It could add to it. The extra person has to be 'managed". to be effective. Nev

 

 

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It's going to be hard to set controls/limits

 

With relying on personal minimas it still has plenty of ways it can go below them. it might be ok on departure but because the weather is so changable and change to ifr while in flight. And how do you enforce personal minimas?

 

If they set an external control - eg an angel flight controller who checked the weather and said yes or no - that person then ends up wearing the blame if it goes pear shaped.

 

I'm afraid I have to disagree about dual pilots. That's asking for trouble. You always end up with one more courageous than the other and unless they work together all the time there's still heaps of potential to end up in trouble especially when the pressure is suddenly on.

 

Something that lay people don't appreciate is the self pressure to go that crew get when there is a medical slant to the the mission. I can recall when I was a flight physician on our rescue helicopter ( before I got my own pilot licence) that I used to get quite annoyed when the pilots would pull the pin on a mission when it seemed to me so imperative that we went to this persons rescue. Later I realised just how dangerous some of those missions would have been.

 

To be honest as altruistic as it is and despite the lump in the throats effect when I see the ads for angel flight I always think to myself we should leave the medical flying stuff to the professionals and if the professional s won't fly in anything unless it's multi-engine ( or a least pt-6 equipped singles in the shape of PC-12s) and the pilot has cpl and ifr rating etc etc then perhaps we should do likewise.

 

Just because it's done out of the goodness of our hearts doesn't mean we should be doing it less safely. Its a case of you can fly thousands of people to their appointments but as soon as you kill just person it is no longer worth the risk.

 

 

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Exactly right facthunter. So many issues with mandating an untrained unplanned two person crew, be that person a PPL or CPL. Who is the PIC? What authority does the non PIC have? How are they going to manage and resolve conflicts? What duties does the second pilot fulfill? Way more issues raised than issues fixed.

 

 

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It's the passengers and medical profession who need educating. CASA has made a good attempt to educate the pilots, although I didn't know of it till this thread.Remember how Paul Keating got angry when a flight was delayed by his pilots because of weather? Luckily, they were able to stand their ground, unlike the Polish lot where the president and his entourage and the pilots all died.

If CASA won't do it, then Angel Flight need to make up a letter to explain to the non-pilots involved about how the flight could be cancelled or delayed by weather. This would make it easier for the pilot to stay on the ground. It would especially help if the medical specialist had agreed beforehand that the appointment would be flexible in this situation.

No, it's not. AF put no pressure on the pilot to 'push on' its the PIC responsibility to manage their pax, regardless of how happy/unhappy they are. As nev said it's a lesson for US in HF. This is where experience comes into it.

 

There is also a large difference between multi crew ops (which this would never be for private ops excluding the citation) and carrying a second pilot. An inexperienced pilot carrying a second more experienced pilot COULD be a good idea for some but shouldn't be mandated because as I said there is a broad spectrum of pilots. Where you get into trouble is with two inexperienced pilots, one can easily reaffirm the others poor decision making.

 

 

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I should also add I've cancelled 3 AF flights, 2 Because of WX whilst IFR in a capable AC and once because I had something unexpected come up. At all times AF were supportive and thankful.

 

 

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After a relatively quick (2 hours) search of the regulations, all I could find to determine VFR conditions and if it is legal to take off for Day VFR is as follows;

 

1. Forecast - If you can obtain a forecast then cloud must be at least 1000' AGL above the highest obstacle 10nm either side of track

 

If no forecast then pilot is satisfied that the weather at the departure point will permit the safe return within 60min.

 

2. Alternate - The forecast cloud must be Scattered or less, 1500' AGL and 8km vis (not applicable if less than 50nm)

 

3. Takeoff/Enroute/Landing - Class G: below 10,000' - 1000' vertical, 1500m horizontal, 5km visibility. AT or below 3000' AMSL/1000'AGL; clear of cloud and in sight of ground or water, 5km visibility - MUST HAVE a radio and used on appropriate frequency.

 

4. Reg 157 may fly below 500' due stress of weather.

 

For IFR the take-off minima is black and white, but for VFR it can be down to interpretation; for example, there are no TAF's for my departure, destination or any airfields along my track. The ARFOR that I have obtained shows cloud above 1500' and visibility of 8km. However at my departure the cloud is low and I estimate that it is 800' and I guess visibility to be 5km and I'm satisfied I can make a safe return. I do not need an alternate due to forecast. I jump in the plane and take off. At 600' I start entering cloud, I drop to 500' and can see the ground and if need be due to press of weather I can fly less than 500' if I need to so I head off to my destination. Have I broken any Visual Flight Rules?

 

Please provide references to any rules that have been broken.

 

 

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"WE (RAAus) did some form of it (which I think should be revisited and introduce an interactive on-line refresher/ follow up"

 

Could not agree with that one Nev.

 

Don't encourage them to introduce more BS.

 

One cannot legislate commensense.

 

 

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Well Frank, you either do HF properly or you haven't done it. It seems clear that WE need it. It's been done around the world with forward thinking flying groups with a relatively low cost base improvement in safety. It's never made anyone less safe. WE being the fly for fun lot. Who don't have to run to fixed schedules, and can fly when we choose to and pick out weather that suits us, not scares us.. Many who don't agree with Human Factors being addressed are the ones who tend to need it most. That's been observed on courses conducted over the years. The ones who roar into it thinking it's commonsense and embarrassingly end up looking foolish by missing what appeared to be obvious on later examination.. Trouble with commonsense is it's not common enough and has little sense in it sometimes.

 

I Don't include you it that statement, because frankly I don't know enough about you and I don't like passing judgements on people anyhow. I also abhor BS and we get plenty of it in a game where it has no place. I'm not one for more rules. I believe Knowledge and understanding beat "just do it this way" all the way through the whole exercise.

 

CONFUSING RULES are also a human factors issue. Anyone charged with putting them out has the responsibility of making them comprehensible and clear as to purpose and intent. People who make the rules should know what they are talking about. That's Rule # ONE.

 

RAAUS "did" HF, but it's not a pass and " Done, that's it crossed off" thing, nor was it done well overall though it may have been fairly well done in some individual cases. We did it because we HAD to. Some one said so. We must approach it as to be done because WE need it and it's ongoing. We even need to be instructed how to scan the airspace for it to be effective, because the eye fills in with empty space what you don't look at hard enough in a disciplined way, to see. We invent reasons why getting there quickly is important. We show off at the slightest provocation. Plan to arrive just before sunset with a wind that requires flying into the sun for landing. and much more..... Nev

 

 

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After a relatively quick (2 hours) search of the regulations, all I could find to determine VFR conditions and if it is legal to take off for Day VFR is as follows;1. Forecast - If you can obtain a forecast then cloud must be at least 1000' AGL above the highest obstacle 10nm either side of track

If no forecast then pilot is satisfied that the weather at the departure point will permit the safe return within 60min.

 

2. Alternate - The forecast cloud must be Scattered or less, 1500' AGL and 8km vis (not applicable if less than 50nm)

 

3. Takeoff/Enroute/Landing - Class G: below 10,000' - 1000' vertical, 1500m horizontal, 5km visibility. AT or below 3000' AMSL/1000'AGL; clear of cloud and in sight of ground or water, 5km visibility - MUST HAVE a radio and used on appropriate frequency.

 

4. Reg 157 may fly below 500' due stress of weather.

 

For IFR the take-off minima is black and white, but for VFR it can be down to interpretation; for example, there are no TAF's for my departure, destination or any airfields along my track. The ARFOR that I have obtained shows cloud above 1500' and visibility of 8km. However at my departure the cloud is low and I estimate that it is 800' and I guess visibility to be 5km and I'm satisfied I can make a safe return. I do not need an alternate due to forecast. I jump in the plane and take off. At 600' I start entering cloud, I drop to 500' and can see the ground and if need be due to press of weather I can fly less than 500' if I need to so I head off to my destination. Have I broken any Visual Flight Rules?

 

Please provide references to any rules that have been broken.

If the NAIPS forecast is for 3500 metres visibility against the legal requirement for 5000 metres, and the NAIPS forecast is for overcast (solid cloud) at 200 feet against the legal requirement to fly above 500 feet (and maintain the legal vertical distance from cloud at that minimum height), I would be considerably short of my legal obligations on either one and there's no possible way I would be committing to flight. (We would not be flight planning to take off from the safety of the ground and fly below 500 feet due to stress of weather; that's there for when the weather was legal at take off but closes in en route).

 

 

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The ones who roar into it thinking it's commonsense and embarrassingly end up looking foolish by missing what appeared to be obvious on later examination.. Trouble with commonsense is it's not common enough and has little sense in it sometimes.

No wish to argue, just my opinion. Yes I have completed the RAA HF course and was quite frankly embarrassed by some of the comments being made by some IMO shouldn't be in charge of a lawn mower.

 

After over 35 years of PVT & COM ops (including IFR) I find it difficult to put up with academic crap from non pilot academics. I accept you have more experience then me but I do not accept the push for this type of stuff. Should I make a mistake in the remaining years I have left to fly, then I would be happy for people to say he made a HF mistake because he didn't agree with push, I know I would have a "mistake" but some people need a box to put it into.

 

People make a living out of this stuff but IMO those who need it most really most will not change anyway.

 

IMO there is 3 important things

 

1. Get the weather and know what it means.

 

2. Know your own limitations & currency.

 

3. Know the aircraft/instrument limitations (I have listened to some frightening opinions on this alone)

 

I accept some people thrive on this sort of stuff, it is just not me.

 

 

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It's not fair to judge something by a poorly executed example. You wouldn't compare the first cars with todays articles. Studying the effects of oxygen deprivation hypoxia. Carbon monoxide effects on your body. dehydration, blood sugar level, Blacking out under "G" load, fatigue, fear, stress and things like that all are part of the picture. Having lot's of experience doesn't count if you are failing in predictable ways to manage the situation well. I've seen experienced people develop an irrational fear of weather when it's all part of the scene they have been in for years. You may be like me a bit of a rebel and non conformist. I don't like to be pushing HF but it's a responsible thing to do with a proven improvement in analysing errors pilots make. The individual can develop the ability to recognise a trap He/she is getting into by being more aware of how the "human" works. Anyhow, I'll finish for now. I hope a few more people will think about it. Nev

 

 

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No wish to argue, just my opinion. Yes I have completed the RAA HF course and was quite frankly embarrassed by some of the comments being made by some IMO shouldn't be in charge of a lawn mower.After over 35 years of PVT & COM ops (including IFR) I find it difficult to put up with academic crap from non pilot academics. I accept you have more experience then me but I do not accept the push for this type of stuff. Should I make a mistake in the remaining years I have left to fly, then I would be happy for people to say he made a HF mistake because he didn't agree with push, I know I would have a "mistake" but some people need a box to put it into.

People make a living out of this stuff but IMO those who need it most really most will not change anyway.

 

IMO there is 3 important things

 

1. Get the weather and know what it means.

 

2. Know your own limitations & currency.

 

3. Know the aircraft/instrument limitations (I have listened to some frightening opinions on this alone)

 

I accept some people thrive on this sort of stuff, it is just not me.

Hi Frank - I must agree with you mostly and here is a bit of history - I have flown for 35 years ish as a com and RAA pilot.

 

I must be also sceptical of the Human Factors to the point of back in the day.

 

I and others "survived without any HF training" as it was not invented then and with the bad old days of slightly bending rules that were done for commercial reasons and were common place. Not talking about Jet stuff but the smaller companies with single and twin engine aircraft doing charter etc when you really learnt to fly not at controlled airports.

 

And yes they were real cowboys out there. However the military boys doing airshows also had some as well, for example, we all had some drinks at night and did the airshow the next day.

 

Same with some of the drivers doing commercial demos with new aircraft.

 

Working for a charter companies also provided Real stress, that was, Don't do the flight, the company don't get paid and you don't get paid and or be replaced and out of a job was common back then, as plenty of new commercial pilots were around to build hours and take your job.

 

Other things such as past last light landings at ALA'S, overloaded, fuel below required reserve, cancel SAR early when late and not in circuit were done at times.

 

However nothing was really done by CASA.

 

We are never going to be 100% free of crashes or deaths ever, because all of us are humans and are stupid at times when you look back in hindsight.

 

Now back to RAA sport aircraft - weekend pilots(not being rude) will always make mistakes due to limited experience in the seat and are human same as GA PPL and new shinny commercial pilots and old pilots having a senior moment - AS WE ALL HAVE and will.

 

How will we be trained out of that - oh I forgot we will be grounded for thinking of going flying not in the to distant future.

 

If you have a RAA 75 year old or 85 year old who hold a drivers licence or they are in GA and pass the medical are you going to ground them because they might make a mistake in the future with Human Factors, compared to the kid that's 17years old with 20 hours will make a mistake sooner or later.

 

 

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The human factors training is not a gimmick. The material contained is very realistic and relevant, and I have seen a great deal of it in my time flying so far. You can pay it off as all been common sense and unimportant, but given you are a human being you are equally liable to encounter the human failings covered in the training course. It's very easy to sit there and say that guy is an idiot and I would never make that mistake, but a wiser person learns from it and realises that it could just as easily be them that made the error.

 

 

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  • 4 weeks later...

ABC 7:30 REPORT - Tuesday 25th July 2017

 

There will certainly be some activity following this segment, which included guarded comment from CASAs' Peter Gibson. This recent Mt Gambier accident was compared to the night accident near Horsham some years back. The qualifications and experience of both pilots was discussed. An aviation industry consultant called for CASA to mandate higher quals and experience. A family member of the Horsham victims called for victims' families to commence immediate legal action against accident pilots, including placing a caveat upon all their property. Despite the fact that an inquiry into AngelFlights' operations several years ago, that did not initiate any change at all - this time things might just be different.

 

 

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ABC 7:30 REPORT - Tuesday 25th July 2017There will certainly be some activity following this segment, which included guarded comment from CASAs' Peter Gibson. This recent Mt Gambier accident was compared to the night accident near Horsham some years back. The qualifications and experience of both pilots was discussed. An aviation industry consultant called for CASA to mandate higher quals and experience. A family member of the Horsham victims called for victims' families to commence immediate legal action against accident pilots, including placing a caveat upon all their property. Despite the fact that an inquiry into AngelFlights' operations several years ago, that did not initiate any change at all - this time things might just be different.

In both cases, the Met factor has come under serious criticism, so that will inflame the situation.

 

Angel Flight's arm's length relationship to the private pilots carrying out the service might also now come under scrutiny; someone had to be carrying out a duty of care to avoid a reasonably forseeable risk.

 

 

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ABC 7:30 REPORT - Tuesday 25th July 2017There will certainly be some activity following this segment, which included guarded comment from CASAs' Peter Gibson. This recent Mt Gambier accident was compared to the night accident near Horsham some years back. The qualifications and experience of both pilots was discussed. An aviation industry consultant called for CASA to mandate higher quals and experience. A family member of the Horsham victims called for victims' families to commence immediate legal action against accident pilots, including placing a caveat upon all their property. Despite the fact that an inquiry into AngelFlights' operations several years ago, that did not initiate any change at all - this time things might just be different.

The report was not balanced in my opinion. The previous victims husband advocating caveats on the pilots property will kill this charity. The guys who do it have a few bob I suggest so they have lots to lose. Why would they continue to do it now? All they people will now have to drive 1000's of km and suffer.

 

 

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The bottom line is, that Angelflight is indulging in an operation that requires the display and execution of professional management, relating to the entire operation - which is currently taking risks with passengers lives.

 

If the pax were asked to sign an agreement that their AF flight was dangerous, and they were risking death due to the low level of voluntary AF pilot competence, then perhaps they wouldn't fly - or if they did, Angelflight and the pilots would be covered.

 

AF pax safety is currently a very low level priority with AF.

 

Essentially, too many people have been sitting on their hands since the Horsham AF crash.

 

Flight safety is all about identifying aviation problems and initiating improved procedures/training/flight requirements, after the causes of any particular crash have been identified with a substantial degree of certainty.

 

The problem with the Horsham crash was quickly identified - yet nothing was done to prevent a repeat of the crash.

 

The Mt Gambier crash appears to be a nearly identical event to the Horsham crash - but still CASA and Angelflight are sitting immobile like stone Buddhas, and navel-contemplating like Buddhas, as well.

 

Immediate action needs to be taken to ensure that a third AF event along the same lines, doesn't happen again, soon. And with the navel-contemplating going on, that will soon become a certainty.

 

 

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I reckon the single thing missing is for people to have the right to do things at their OWN RISK.

 

Then you could decide to take an angel flight or drive the 500k. You could decide to have the baby in your home town or go to a capital city for weeks.

 

The only law you would need would be the criminal one, such as if your pilot or doctor turned up drunk.We already have that law, what we don't have is the ability to decide if we want to do something at our own risk.

 

 

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I reckon the single thing missing is for people to have the right to do things at their OWN RISK.

The "if I screw up, you have to fix your own problem era ended in 1932."

It's not coming back for the simple reason that the most appropriate person to shell out the $6 million it will cost to allow the victim to live out his life with a roof over his head, is the person who screwed up.

 

The only law you would need would be the criminal one, such as if your pilot or doctor turned up drunk.We already have that law.

That's culpable negligence, where you know, or ought to know that what you are doing is wrong......like flying below 500 feet, flying without the required distance from cloud etc. and that could get you some time in the slammer.

 

we don't have is the ability to decide if we want to do something at our own risk.

Where you can't hurt someone else, you don't need a right or ability; you're hardly going to sue yourself.

However, if you're flying and you are negligent and the aircraft or a component falls on someone, or you hit a power line and someone is electrocuted in the aftermath you go back up to the first or second example.

 

 

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Being able to take risks if YOU want to is fine in theory, and I fully support that principle, but the average person does not know the extent of the risk in an example like this and is likely to take the view it's run/approved by the government and must therefore meet the "normal" safety rules. The passengers are users of the system not part of it's formulation, don't know the skill of the pilot, and are not in a position to pick and choose any pilot they know of, or prefer. If you charter a plane to take a football team to Brazil, It's operating under much less strict conditions/ requirements than RPT and charter has a much lower safety record for that reason. Nev

 

 

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Being able to take risks if YOU want to is fine in theory, and I fully support that principle, but the average person does not know the extent of the risk in an example like this and is likely to take the view it's run/approved by the government and must therefore meet the "normal" safety rules. The passengers are users of the system not part of it's formulation, don't know the skill of the pilot, and are not in a position to pick and choose any pilot they know of, or prefer. If you charter a plane to take a football team to Brazil, It's operating under much less strict conditions/ requirements than RPT and charter has a much lower safety record for that reason. Nev

Yes, there's a big gap in training and skills between a CPL flying multiple hours every day in commercial operations, and a PPL who flies maybe 50 hours a year

 

Most members of the public would have the expectation that the safety level would be the same as a QANTAS flight, unless they were briefed otherwise.

 

 

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