RA-Aus Don't Know How to Do "Occurrence Management

[APenNameAndThatA]

A couple of years ago, I was involved in an incident at Caboolture. I sent RA-Aus a written statement. Later, *without them ever speaking to me at all*, the following turned up in my account when I logged in one day, the following appeared, 

 

"Whilst conducting circuits the pilot observed a Piper Pawnee tug about 30 to 50 m to their right and then a couple of meters in front and higher than them. The pilot then made a radio call to the tug saying that they were directly beneath them on downwind. No response was heard. The pilot made a full stop to discuss with their instructor. Investigation revealed poor communication between the two aircraft contributed to the proximity event. Pilots are reminded of CAAP 166 - Operators at non-controlled airports for required procedures, calls and requirements."

 

After I discussed the matter with them, RA-Aus changed the occurrence report to the following. 

 

"Whilst downwind the pilot observed a Piper Pawnee tow plane above them. The pilot then made a radio call to the tug saying that they were directly beneath them on downwind. No response was heard. The pilot made a full stop to discuss with their instructor. Review of this occurrence indicated that both pilots reported to make radio calls, however it is unknown why two-way communication was not established. The pilot of the tow plane was briefed to ensure they continue to see and avoid other aircraft when operating."

 

I was prompted to post this because someone on this forum (quite reasonably) posted that a technical person at RA-Aus said that people did not tell RA-Aus about human factors things so it was hard for RA-Aus to deal with them (or words to that effect). My point is that, when it comes to incident investigation, RA-Aus is pure amateur hour. A while ago I think I posted that there had been a year with fewer than average accidents and RA-Aus said in one of their emails how safe how safe flying was. IIRC, I emailed them back to let them know that about random being more irregular than people think and about regression to them mean. They emailed me to say that they would "engage with" me. I left them to it. 

 

 

 

 

[Garfly]

I'm interested in your original report. 

I'm curious to know what happened in that interval between their noticing the Pawnee pulling up alongside and that subsequent "discussion with their instructor". That's the interesting bit - and where the best lesson lies.  It's like you suddenly find yourself in formation - but NORDO and mutually clueless.  I guess one plan would be to break left onto a mid-field 'base' and come around again (as long as there was no opposite traffic on mid-field cross wind).  Or make an immediate climb straight ahead, up and out of the circuit - all the while keeping your Pawnee mate in sight in case he suddenly sees you and has the same idea (but you'd need to be sure there was nobody above on an overhead join).  Or you could slow down and widen out behind (but you're probably already fairly slow and, again, you'd be hoping he doesn't do the same). Could be tricky.

What did you do?  

[facthunter]

Watch your rules. If you're overtaking do it to  the right. so you'll widen the circuit under those circumstances . Most croppies enter and leave the circuit low. Nev

[APenNameAndThatA]

I just flew straight ahead. I suspect the pawnee pilot had got lazy and was descending on downwind and not really listening or making calls. 

 

Apparently, the other pilot had complained that I had made incorrect radio calls. I had made incorrect radio calls. I had about 20 hours and was soloing with an instructor observing me from the ground. I had not been at Caboolture before and was mixing up the runway numbers between Caboolture and Archerfield because they were similar. Of course, that I was messing up the radio calls should have just been a warning that someone was flying who did not know what they were doing and to watch out. 

 

It’s all not so good with tug pilots dragging that tow rope behind them. Both out radios were working because I could hear him make other calls and he complained about my calls. 

[facthunter]

I don't think it's good form to start challenging someones performance over the radio at the time(if that happened).  IF you are at some NEW place have a card with the essential info there clipped where you can see it ' Runways and aerodrome alt and frequencies to refer to and maybe tower Phone number.. Don't trust your memory. Where training is going on a fair bit of latitude should be allowed by all users. Nev

[Garfly]

9 minutes ago, facthunter said:

I don't think it's good form to start challenging someones performance over the radio at the time ... // Where training is going on a fair bit of latitude should be allowed by all users. Nev

You mean like this?    ;- )

 

 

 

[Thruster88]

9 hours ago, APenNameAndThatA said:

 

 

I was prompted to post this because someone on this forum (quite reasonably) posted that a technical person at RA-Aus said that people did not tell RA-Aus about human factors things so it was hard for RA-Aus to deal with them (or words to that effect). My point is that, when it comes to incident investigation, RA-Aus is pure amateur hour. 

Ok I think that someone is me. One of my gripes about RAAus accident and incident is they often appear to be rewritten by someone with zero aviation knowledge. When I flew to the Parkes Flyin for fun April 2 in the RV I spoke with a senior RAAus person about this. They said the reports are  not rewritten. I said well that is a concern and left it at that. 

 

[APenNameAndThatA]

1 hour ago, facthunter said:

I don't think it's good form to start challenging someones performance over the radio at the time(if that happened).  IF you are at some NEW place have a card with the essential info there clipped where you can see it ' Runways and aerodrome alt and frequencies to refer to and maybe tower Phone number.. Don't trust your memory. Where training is going on a fair bit of latitude should be allowed by all users. Nev

As is consistent with your comment, I was not criticising his performance. I wanted him to know I was there. And *now* I keep a labelled sketch of the runways on my kneeboard. 

Edited June 18, 2022 by APenNameAndThatA

[APenNameAndThatA]

15 minutes ago, Thruster88 said:

Ok I think that someone is me. One of my gripes about RAAus accident and incident is they often appear to be rewritten by someone with zero aviation knowledge. When I flew to the Parkes Flyin for fun April 2 in the RV I spoke with a senior RAAus person about this. They said the reports are  not rewritten. I said well that is a concern and left it at that. 

 

One of my gripes about RA-Aus is that their investigations are done by people with zero OH&S, root-cause analysis, legal or natural justice knowledge. 

[APenNameAndThatA]

1 hour ago, Garfly said:

You mean like this?    ;- )

 

 

 

Not being able to admit you stuffed up is a big problem in all walks of life. And trying to get people to admit that they are wrong is futile - and dangerous in this case. 

[Blueadventures]

2 hours ago, facthunter said:

Watch your rules. If you're overtaking do it to  the right. so you'll widen the circuit under those circumstances . Most croppies enter and leave the circuit low. Nev

Pawnee most likely would have been doing glider tows so quick descents to join circuit to do next tow job.

[RossK]

Croppies and Jump planes rarely follow the "rules" in my experience.

I've had a jump plane overtake on my left on downwind. I've had a croppy cut in front on a 200ft right base (I was on a std left base)and a croppy take off with a tailwind on the same runway I was entering and lining up on, ie he took off towards us and passed overhead. To their credit, all were very good with the coms and let me know what they were doing.

No experience with Tugs, but i'd guess they are under the same time pressures.

 

On topic, the RAA reports are a bit wanting, some follow up root causes and preventative actions would be helpful.

[Blueadventures]

12 minutes ago, RossK said:

Croppies and Jump planes rarely follow the "rules" in my experience.

I've had a jump plane overtake on my left on downwind. I've had a croppy cut in front on a 200ft right base (I was on a std left base)and a croppy take off with a tailwind on the same runway I was entering and lining up on, ie he took off towards us and passed overhead. To their credit, all were very good with the coms and let me know what they were doing.

No experience with Tugs, but i'd guess they are under the same time pressures.

 

On topic, the RAA reports are a bit wanting, some follow up root causes and preventative actions would be helpful.

Re reports more substance needed to share unwanted experiences and failures.

[onetrack]

I would expect that RA-Aus doesn't have enough available people with the necessary substantial aviation training and long experience, to be able to issue substantially larger and more expansive crash reports, or experiences or failures, that rate as "important to know". 

I would suggest that perhaps retired aviation people have something to offer in this case, providing further opinions or assessments of RA-Aus incidents that could be presented to them to advise on, as part of the final report.

We no longer have enough people today, of the calibre and dedication of Macarthur Job, to keep up the continuous flow of good flying advice, and the competent dissection of adverse aviation events.

 

Edited June 23, 2022 by onetrack

[facthunter]

It was referred to somewhat irreverently as "The Crash Comic". Good value always and still would be worth perusing. Nev

[jackc]

RA-Aus are our peak body, also our regulators and are always on about Safety which is good, but they need to get up to speed on thorough  detailed incident reports that everyone can learn from.  Everyone stands to learn 🙂 

[jackc]

RA-Aus are our peak body, also our regulators and are always on about Safety which is good, but they need to get up to speed on thorough  detailed incident reports that everyone can learn from.  Everyone stands to learn 🙂 

[Yenn]

RAAus don't necessarily edit the reports, but they have garbled one I put in, making it totally incorrect and stating that I was at fault, even though my report clearly showed I was not at fault. It makes you wonder if it is worth putting in a report to try to help others avoid an incident.

[jackc]

Well, our peak body better get it right, IF any members make a mistake anywhere, RAaus are quick to call them out 😞 

[Thruster88]

This is the report from the recent forced landing in Queensland. The pilot did an excellent job, just unlucky to nose over. He also probably wrote an excellent report however it has obviously gone through the office rewrite for reasons unknown and some of the context and timing of events may have been lost. The reason for the engine failure according to the grape vine doesn't gel with the report as it stands.

 

Will there be a follow up with actual reason for the engine failure, not likely based on history.

 

 

The report:

13/6/2022MelawondiQLDJabiruUL450Jabiru2200STATUS: Under review OCCURRENCE DETAILS SUBMITTED TO RAAUS: The aircraft departed Gympie AFLD ab... 

STATUS: Under review OCCURRENCE DETAILS SUBMITTED TO RAAUS: The aircraft departed Gympie AFLD about 10 minutes before intending to track to Warwick to refuel before continuing to home location in NSW. Just trimmed for cruise at 2500' to assess nav settings and level. The pilot noticed a slight drop in altitude and thought the throttle might be loose. It was not loose, no response. All Ts and Ps looked ok. Then the prop stopped. A restart was attempted but the starter did not budge. The stopped prop was indicating an engine seizure. The pilot contacted another aircraft on 121.5 passed on their information and situation. They indicated they had ADS-B out for further accuracy as they were too busy looking for set down field to take eyes off the airspeed indicator and terrain. Set best glide speed. The pilot saw an airstrip below, but surrounding trees and orientation looked more risky than surrounding paddocks. An adjacent paddock was clear and attainable but on finals the pilot noticed it appeared to full of livestock, so they turned for paddock beside nearby house noting fences across landing path. Committed below 200' AGL had to avoid fences. 1 notch of flaps on base turn at 100'. Full flap near last fence with enough energy for slight clearance over fence. The aircraft immediately drop onto mainwheels on the downhill slope. Soft ground pulled up the landing roll to less than 35 metres. Nosewheel settled and dug into the soft ground tipping the aircraft onto its nose. It almost balanced there and stopped, then fell onto its roof. The only minor injury to the pilot at that point was a bump on the head on the Perspex skylight above (now below). The pilot lowered themselves onto roof inverted as seat belt undone and opened undamaged door to egress.

[Old Koreelah]

Impressive landing, considering the situation. Near a house is always a good idea. Livestock is a factor; even if you miss them on landing, cattle are likely to do some damage to a parked aeroplane.

[Blueadventures]

7 minutes ago, Thruster88 said:

This is the report from the recent forced landing in Queensland. The pilot did an excellent job, just unlucky to nose over. He also probably wrote an excellent report however it has obviously gone through the office rewrite for reasons unknown and some of the context and timing of events may have been lost. The reason for the engine failure according to the grape vine doesn't gel with the report as it stands.

 

Will there be a follow up with actual reason for the engine failure, not likely based on history.

 

 

The report:

13/6/2022MelawondiQLDJabiruUL450Jabiru2200STATUS: Under review OCCURRENCE DETAILS SUBMITTED TO RAAUS: The aircraft departed Gympie AFLD ab... 

STATUS: Under review OCCURRENCE DETAILS SUBMITTED TO RAAUS: The aircraft departed Gympie AFLD about 10 minutes before intending to track to Warwick to refuel before continuing to home location in NSW. Just trimmed for cruise at 2500' to assess nav settings and level. The pilot noticed a slight drop in altitude and thought the throttle might be loose. It was not loose, no response. All Ts and Ps looked ok. Then the prop stopped. A restart was attempted but the starter did not budge. The stopped prop was indicating an engine seizure. The pilot contacted another aircraft on 121.5 passed on their information and situation. They indicated they had ADS-B out for further accuracy as they were too busy looking for set down field to take eyes off the airspeed indicator and terrain. Set best glide speed. The pilot saw an airstrip below, but surrounding trees and orientation looked more risky than surrounding paddocks. An adjacent paddock was clear and attainable but on finals the pilot noticed it appeared to full of livestock, so they turned for paddock beside nearby house noting fences across landing path. Committed below 200' AGL had to avoid fences. 1 notch of flaps on base turn at 100'. Full flap near last fence with enough energy for slight clearance over fence. The aircraft immediately drop onto mainwheels on the downhill slope. Soft ground pulled up the landing roll to less than 35 metres. Nosewheel settled and dug into the soft ground tipping the aircraft onto its nose. It almost balanced there and stopped, then fell onto its roof. The only minor injury to the pilot at that point was a bump on the head on the Perspex skylight above (now below). The pilot lowered themselves onto roof inverted as seat belt undone and opened undamaged door to egress.

Hi T88  What do you recon if we set up a thread where by incidents are posted and findings discovered by the washup including RAA feedback are posted by the persons or persons involved.   For example I had an exhaust header touch a coolant hose on a R912 and did a precautionary landing and then fixed the issue with great assistance and was then back on my way.  I post the report and outcome lesson learnt tomorrow or next day.  Today is my birthday, another one down,  just back from Top Gun Maverick' and out to dinner with friends; then a full day tomorrow with out of town visitors.  Such may be a way of getting learning out amongst us.   Would not like any thread to get off topic. Cheers.

[jackc]

As Nike would say ‘Just Do It’  🙂

[Roundsounds]

The concept of publishing all incidents is flawed. The organisation should be collating all incident reports, investigating and categorising them under headings such as phase of flight, level of experience, weather conditions and causal factors. The purpose of this method of reviewing incidents is to identify any trends, then focus on the most effective way of addressing these trends. Selected  de-identified reports relating to the concerning incidents could then be published to help with any subsequent mitigation action. This action may include online training, videos, targeted flight training, mandated AFR training or roadshow type presentation to mention a few. The current method is simply ineffective. 

Edited July 18, 2022 by Roundsounds

[facthunter]

As it is it lacks effectiveness. Not enough analysis and if they did it would probably be erroneous often.. One of the main purposes is to alert other pilots to what has occurred. Remedial/ /punitive is extra to that purpose. Unidentified reporting suites the first purpose and has been encouraged from time to time. ANY person becoming aware of an unusual and potentially dangerous operation of aircraft has a legal obligation to report it. Nev