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Lockhart River Qld. Plane crash. 11th March 2020.


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How often have CASA said that commercial pressure was the reason for the crash? Ever since the Whyalla disaster, I have blamed CASA as being a contributing cause.

What would have happened to the pilot if he had abandoned the planned flight? Would he have got the sack? If that happened, would CASA have protected him?

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Guest Machtuk

We will never know definitively whether commercial pressure was a contributing factor in this accident (more than likely though) but it's very real in the industry especially at the GA Level just not able to be proven. I've had it weigh on my mind many times over the years as well as other factors where hindsight would have most likely made me make different choices. Pilots are human, there's volumes written on us about human factors etc but mostly it's just 'feel good' stuff as even though you can make a 100 identical airframes right down to the colour of the toilet flush button you will NEVER make any 2 pilots the same! It will happen again, it's a fact of life ?

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I agree.

 

Everyone wants to write off accidents off as "Ah yes, just pilot error. I would have just turned around". People that say that completely miss the commercial pressure, I think they even misunderstand what commercial pressure is. Maybe a better word would be "External Pressures".

 

Speaking hypothetical, because we have no knowledge of the flight or conditions. But hypothetically this or ANY pilot for that matter could be under commercial pressure. Perhaps this pilot was paid pretty typically, which is per flight hour or nautical mile flown. BUT only on a successful trip. Cool, I am only going to get paid this week if I get in to this airport in shitty weather, and I have already left. I have a wife and kid at home...... What else? Well the boss is going to be real mad I just spent 1500 dollars in fuel for no income. Maybe the pilot is worried he would lose the job because he just cost the business 1500 and lost time on the aircraft. Maybe the pilot is new, trying to impress the owner by 'getting stuff done'.

 

Maybe the pilot hasnt shot an NDB approach in real hard IFR conditions before? Or perhaps just isnt as current as they would like, but there is a job to do and money to be made.

 

Perhaps they had planned to collect barrel fuel at Lockhart that was pre purchased, so the pilot accepted going up on minimum fuel. The pilot probably had done this a few times and never had any issues.....(Normalization of Deviance) but on this flight ran out of options. Commercial pressure is not just "I have a job", but it can be internal professional or personal pressures.

 

If anyone says that commercial pressure doesn't exist in Australian general aviation has never worked in Australian general aviation. Our crash reports are littered with the background rumblings of commercial/external pressures. Here is one of those reports, https://www.atsb.gov.au/media/24353/aair200105618_001.pdf . Young/new pilot flying a King Air, training was conducted by the operator. Pilot was taught to fly the aircraft off the ground at 90, no where near Vmca, and well below even the recommended rotation speed in the manual. But if the boss/owner/however tells you this is what we do, well you go ahead and do it. Its your job. They are paying to train you. You dont ask questions. Engine failure right at the incorrect rotation speed, no runway to stop, no room to accelerate. Just confusion and 20 seconds to live.

 

Having a job in Australia is hard. Having an aviation job is Australia is even harder. No one is talking about that. Nothing in the ATSB reports. Nothing from CASA. The occasional corona's report points the finger the right direction, but that information is never in the factual ATSB reports. The systemic problems are the cause for the majority of these incidents, its just how far you zoom out on the incident.

 

By the time CASA got to this case, the operator just ceased operations. Just stopped. No safety action required, business doesnt exist any more. No changes, regulations or protections for pilots to stand up to commercial pressures, no incentives. Pilot and passengers die, and the owner operator is free to close and reopen under a new name. The people on the ground have a chance to learn/change/cover-up from the mistakes, but only AFTER the mistakes have been made.

 

The trick that ICAO investigators use, is keep asking WHY until there are no more answers. WHY was there pilot error. WHY were there commercial pressures. WHY do those pressures exist.

 

Dismissing an incident as pilot error is just laziness. No pilot wakes up in the morning, looks in the mirror and says "You know what? Im going to fly into bad weather and crash today!".

 

Why did they take off. Why did they continue the flight. The answer is not pilot error.

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There is a golden rule for bad weather landings.

"Try once and if you know how to fix a miss approach try again. If unsuccessful try the alternate."

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It depends on the circumstances. If the weather is fluctuating near minimum and you have fuel and you are not overloaded work wise why not ? I don't believe prescriptive "rules" are any more than a guide.. They can never be absolute for ALL circumstances. Nev

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Every crash has a 'human factor' about it, afterall its humans that drive these machines. As I mentioned above commercial pressure is a very real threat, that's one major factor in most of these types of events although rarely proved.

 

The most important thing that a professional pilot can do is to avoid allowing the 'commercial expectations' to become an 'operational imperative'. Sometimes the companies' ground staff can oversell things to the prospective charterer.

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Real world GA is there is always commercial expectations and operational imperatives, you wouldn't get or keep a job without that. People working for nothing or very little don't have a choice but do what their told.

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Real world GA is there is always commercial expectations and operational imperatives, you wouldn't get or keep a job without that. People working for nothing or very little don't have a choice but do what their told.

 

I have this argument every day.

Drivers complaining about being forced to do stuff they are not comfortable with.

My answer is always the same, just don't do it.

There are no buts or what ifs, if it is not legal or not safe do not do it.

If enough people stand up for what is right we all win.

And before anyone says it is easier said than done, it is easy to do.

I have lost so many customers because I refused to run overweight or over hours etc, but the customers that I keep are bloody good ones.

 

I have what I call the Grandfather test, when I do something with a truck or any vehicle, I ask myself this question,

"Would I drive this down the street where my Daughter is dropping my Grandkids at school?"

If the answer is no then it simply does not move.

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Guest Machtuk

I have this argument every day.

Drivers complaining about being forced to do stuff they are not comfortable with.

My answer is always the same, just don't do it.

There are no buts or what ifs, if it is not legal or not safe do not do it.

If enough people stand up for what is right we all win.

And before anyone says it is easier said than done, it is easy to do.

I have lost so many customers because I refused to run overweight or over hours etc, but the customers that I keep are bloody good ones.

 

I have what I call the Grandfather test, when I do something with a truck or any vehicle, I ask myself this question,

"Would I drive this down the street where my Daughter is dropping my Grandkids at school?"

If the answer is no then it simply does not move.

 

 

What type of charter flying do you do?

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What type of charter flying do you do?

 

It has nothing to do with what the business is it is about right and wrong.

I was simply highlighting that commercial considerations affect all business and there is absolutely no reason to swap commercial decisions for safety.

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I have this argument every day.

 

There are no buts or what ifs, if it is not legal or not safe do not do it.

 

If enough people stand up for what is right we all win.

 

"Would I drive this down the street where my Daughter is dropping my Grandkids at school?"

If the answer is no then it simply does not move.

 

I agree with everything you say in principle.

 

However its orders of magnitute easier to negotiate a commercial deal in an office as a manager without the operating pressure.

 

In GA the pilot it not the one doing the negotiations, or setting up the job. The pilot is left with making the operational decision to go, after someone else has agreed to the flight.

 

Now sure its the pilots job to decide if operationally the flight can be done. Weather at minima? Cool plan an alternate. Carry extra fuel. In theory the risk is managed in a legal sense. There is no legal protection or guidance when weather is marginal. So guess what happens? Pilots launch, to "see if they can poke their nose in". There is always my alternate and extra fuel.

 

One of the best test pilots I ever learnt from, had a saying. "Before i get in any aircraft, I assume my IQ will half when the engine starts". He is not saying he is dumb. He is saying his ability to make good decisions in a timely matter go out the door.

 

Imagine trying to make a decision in hard IMC, getting smashed by the weather, 3rd approach, distracted trying to make a decision while flying the plane on missed. Opps. missed that partial loss of power on the geared engine as there was no real engine note change. Opps below blue line. OOps Vmca in IMC.

 

The ability to make sound decisions deminishes right when we need it the most simply because we are human.

 

You're right. Dont fly the mission.

 

But the closest legal argument you could have is if the alternate you file is also below minima. If your alternate is below westher minimums, you are NOT legally allowed to fly (unless you have holding fuel to last out the weather). So that leaves us in a position; If its legal you are obliged to make the flight. Its your job. Its why the boss hired you. They dont care about your personal minimums. The business have their own.

 

Aviation in small in Australia, you get a name for not completing flights because of the weather? No one will hire you. We live in the grey area of the law here, because thats the only way the industry has stayed alive.

 

99% of flights dont end in accidents, even flights that depart over weight, outside legal rules, outside personal minimums, in aircraft under maintained. We only turn on the microscope after the accident.

 

The thing is, what is legal and what is safe are NOT INTERCHANGEABLE in aviation.

 

Sometimes operating under legal rules is whats safe. Other times doing what is legal is unsafe. And then there is doing illegal things that are actually safe. (4th One is doing illegal things that are unsafe).

 

I am sure you could think of a huge list of items that are technically illegal but are safe or safer to do.

 

So thats the fundamental hole in aviation law. What is legal is not nessisarily safe. So following the rules alone, is not enough to build safety. But if the only LEGAL protection we have as professionals IS the law, we have no protection to argue.

 

Like you said in your post. Absolutely we have the abilty to argue. Say no. But if our only reference point is "its my personal minimum" you will get laughed at and told to "show me in the regulations why you cant fly".

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Guest Machtuk

It has nothing to do with what the business is it is about right and wrong.

I was simply highlighting that commercial considerations affect all business and there is absolutely no reason to swap commercial decisions for safety.

 

I thought as much!

What would you know about commercial charter flying unless you've don't it, you've been there with the subtle commercial pressure that's with every pilot !

It has nothing to do with right or wrong otherwise we wouldn't be talking about the realities of GA it's to do about the risks involved in flying, risks that are fluid, the risks of carrying actual people not freight, the risks of not being able to complete the task!

 

Scenario:(nothing like driving a truck!) you plan to fly 8 stock buyers to a once a year stock sale where big dollars change hands. This is your big break after not long joining the company getting the job by the skin of your teeth as the competition was fierce!

You plan the flight and launch legally in good faith. Along the route the WX appears worse than forecast and at your destination it's deteriorated. One of the big players onboard asks 'we are going to be able to land aren't we'? There's the first subtle pressure.

You make an App in low cloud and turbulence, the pax are grumbling mumbling we better land and soon! You miss out & make a missed App. One guy says with a stern voice 'we have a big day ahead we don't want to be late'! More subtle pressure!

You miss out on a 2nd App and are sweating profusely by now. You turn to the pax and say I'll give it one more go then we have to return, it's not pretty the pressure now being put on you is making you feel sick! At the minimum on the 3rd App you still don't see the ground but go a little lower anyway, finally below what you feel comfy with you get kind of visual and circle damned close to the tree tops and nearly forget to put the gear down prior to landing, you pull-up to the gate, it's drizzling outside, 8 grumpy guys get off and disappear in to the waiting mini bus. The rest of the day you feel almost sick!

My "mythical" story could easily fit the very crash we are talking about here!

That's COMMERCIAL pressure, nothing like driving yr truck!!

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Going to throw my 50C in here about commercial pressure. But it is going to need a Delorian 1.21 Gigawatts and a flux capacitor. and set the timings back to the late 80's... I was "working" for a charter company somewhere in Eastern Australia... The company had a contract flying a videotape every day from a studio in a big city to a smaller one for a news broadcast... There were NO excuses it HAD to get there..Ohh its a PA-28, there is a Sigmet current??? So fly coastal at 200 feet... You have had an instrument rating for 24 hours.. so go IFR in a C177 single pilot at night down to minimas just make sure it gets there!!! . If you didn't get it there, there was an entire room of CPL students wanting a chance... There was also the maintenance base that was well away from the normal flying base, last week you flew the C-421 there without an endorsement on type (OK it was 200 hours past TBO on the left engine) so why can't you fly the Beagle 206 there this week? It's being decommissioned so don't worry if you damage it... US aircraft HAD to get there to be fixed.. The C-210 had a tail strike but it's OK just fly it to XXX and they will fix it... .. Then there was the flight in a C-310 to an island destination.. single-pilot + 5 PAX every day of the week... to make it with enough fuel you were WELLLLL over MTOW every flight.. Yet if you dont do it the boss was happy to tell you don't come in tomorrow as XXX will do the next few flights... Ohhh and that job in the NT on the 421's... It depended on the recommendations from down south... You spent every single $ you had, you are eating packet noodles and drinking tap water to get by... You will fly anything and everything and do what it takes to get an advantage... These are real examples I know as I was there to see them!!!

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That's COMMERCIAL pressure, nothing like driving yr truck!!

 

Why do you think they had to bring in all the truck Laws about mileage and hours, rest stops, and the very expensive truck time/distance cameras we have.

 

That's right, people were being killed and killing others due to commercial pressure.

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I have this argument every day.

Drivers complaining about being forced to do stuff they are not comfortable with.

My answer is always the same, just don't do it.

There are no buts or what ifs, if it is not legal or not safe do not do it.

If enough people stand up for what is right we all win.

And before anyone says it is easier said than done, it is easy to do.

I have lost so many customers because I refused to run overweight or over hours etc, but the customers that I keep are bloody good ones.

 

I have what I call the Grandfather test, when I do something with a truck or any vehicle, I ask myself this question,

"Would I drive this down the street where my Daughter is dropping my Grandkids at school?"

If the answer is no then it simply does not move.

Yes, it really is that simple.

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Guest Machtuk

Why do you think they had to bring in all the truck Laws about mileage and hours, rest stops, and the very expensive truck time/distance cameras we have.

 

That's right, people were being killed and killing others due to commercial pressure.

 

I worked for Mobil Oil for 13 years whilst flying commercially, the two industries are entirely different when it comes to commercial pressure and the potential outcomes!

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Some of you blokes don't fly for a living then?

No, that’s true, but I work in the transport industry where gutless individuals can kill people both on the road and in setting specifications because of management pressure.I have never lost an order by explaining that a truck was going to cost $4000 more to make it dynamically stable.

What governments have introduced to the transport industry is Chain of Responsibility legislation where everyone in the management chain can be charged for a driving or loading offence and that has helped.

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I reckon the blame lies with CASA and the government.

If I had my way, a pilot who had done the safe thing would be protected by CASA from nasty actions brought by the pilot's employers.

In the Whyalla example, the pilot would have been sacked if he had done the safe thing and landed at Kadina. But he may well have done this landing if he had known that CASA would come down hard on his employer if there was any nasty retribution on the pilot.

Alas, my guess is that CASA would not lift a finger and so those bureaucrats don't deserve their jobs.

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I reckon the blame lies with CASA and the government.

If I had my way, a pilot who had done the safe thing would be protected by CASA from nasty actions brought by the pilot's employers.

In the Whyalla example, the pilot would have been sacked if he had done the safe thing and landed at Kadina. But he may well have done this landing if he had known that CASA would come down hard on his employer if there was any nasty retribution on the pilot.

Alas, my guess is that CASA would not lift a finger and so those bureaucrats don't deserve their jobs.

 

That's not CASA's role, would never happen in the real world of commercial business!

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I agree, things should be safe for any industry, it's not so.

Just take something like health care, Doctors working 90 hours a week in hospitals, half the number of nurses needed, plus nurses help with the hospitals profits by having to pay for parking at work!

Don't expect help from CASA, if any pilot does come forward they will be the ones worse off, not the company they work for. I have come across people in CASA that were helpful, they are the exception. Nobody wants anything to do with CASA, they are poison.

With most work being casual, expect the pressure to operate with illegal practices to get worse. That's what happens when employees lose any bargaining they had, no choice but do what your told (illegal or not) or no job.

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That's not CASA's role, would never happen in the real world of commercial business!

No, it’s not CASA’s role it is State and Territory role, and the Chain of Responsibility legislation applied to a charter where the pilot committed to a landing because he would be sacked if he didn’t and someone was killed would see the Manager, and the owner of the business doing prison time along with the pilot. Mobil was not a good example because they are doing regular scheduled deliveries. The problem in the transport industry was large Companies offering business to sub contractors on an impossible basis, just like the charters we are talking about. The reason the legislation hasn’t entered the aviation industry is almost certainly because pilots don’t know about it and don’t realise they need to go to State and Territory governments.

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