Gary, I totally agree with you sentiments and from what you posted earlier, I suspect that there would be no way of establishing the true cause of this accident, so any report would be unlikely to go beyond what you already posted - unless a mechanical failure was detected !
I've always thought that the reports I've seen on spinning accidents are pretty useless to learn from. They pretty much always start with being too slow and turning, and never focus on what led up to this - poor judgement of circuit, workload, fatigue, dehydration, other medical issue, instrument failure (I know of one such case where the pilot recovered at less than 100', hence able to determine this !), distraction (other aircraft, radio calls, etc) or a host of other possible out of ordinary events. It is impossible to determine which of these was a factor, making anything except a brief report useless, sadly making repeats inevitable as we can't train out the causes if we don't know what they are. I don't see what the ATSB would be able to add here. Having said all that, I have seen logger/flarm traces used on 3 occasions to help investigate totally different types of non-fatal accidents. The traces made it very clear what had happened and why in 2 of the cases, the 3rd was clearly poor judgement and showed actions completely different to what the pilot reported, but there was no obvious sign as to what the cause of the poor judgement was (although the pilot had spent considerable time above 10,000' with no oxygen, so hypoxia or dehydration may have been a factor). Matt On 25/04/2012, at 23:22 , <[email protected]> <[email protected]> wrote: > Hi Mike, Mike Borgelt in particular, and All, > > Very nicely put. > > I note in particular your comment "...and the amount of knowledge gained from > NZ investigations is not significantly higher than here." I suspect that you > could widen "NZ" to "Worldwide". > > At the risk of seeming outrageous, let me say that to the ATSB and its > previous incarnations, investigating glider accidents is, within the bigger > picture of accident investigation, "just plain boring". > > How so? Let me explain. > > Unless I am missing something, there are basically only two factors to any > gliding accident - mechanical failure, or pilot error( or incapacity). In an > ultimate analysis, everything can be reduced to these two fundamentals. > [There is no doubt that these fundamentals also apply to any accident > scenario where human beings are involved.] > Some pundit will no doubt be able to quote the "exact" figures for gliding, > but in gliding accidents MUCH less than 10% of accidents can be attributed to > mechanical failure. I will leave it to you to work out what the remainder is > allotted to! ....... However, do not jump to conclusions. In (unfortunately > far too many cases), WHAT happened is quite easy to determine. WHY it > happened cannot be determined at all! Nevertheless the fundamental premise > that I have posited above must apply. > > Gliders, in comparison to say modern airliners are relatively simple machines > - just ask the boys in South Africa who developed the JS1.They are reputed to > have put in over 70,000 total hours to get to official Type Approval! > > So, in a few instances of gliding accidents there is a mechanical problem. > As gliders are such simple machines, any mechanical failure should be > relatively easy to determine. This does not require the input of the ATSB. As > Wombat has said, the ATSB generally leaves it to either one of the other two > entities who CAN legally investigate - the State Police, or the State Coroner. > > If you are particularly observant, you will note that neither Wombat nor I, > have mentioned the GFA in this context. Legally they do not have a role. In > practice they are generally requested to supply expert advice to the > Investigating Authority. Apart from anything else, this keeps the GFA "in the > loop". > > [It is a digression, but it would seem in fact that these two bodies > Police/Coroner co-operate. Maybe some legal eagle might be able to explain > just what are the current arrangements, which may possibly vary from State to > State. I posit that in theory each one of the 3 entities is able to carry out > an independent investigation if it so chooses?] > > So much for mechanical failures. > > What about Pilot Error? > > Well pilots have been crashing, and in many cases dying, since man took to > the air. Every possible means of crashing has been explored from that time > until now. I suspect that all the possibilities for human error were > exhausted long ago: Hence the lack of ATSB interest. > > As a result of these experiences the GFA produced a Manual of Standard > Procedures. You are of course perfectly free to ignore the accumulated wisdom > of ages, as set out in this document and taught by every accredited > instructor, but you do so at your peril. > > Regards, > Gary > > > > > > > > ----- Original Message ----- > From: Mike Cleaver > To: Discussion of issues relating to Soaring in Australia. > Sent: Wednesday, April 25, 2012 4:40 PM > Subject: Re: [Aus-soaring] GFA Site/accident > > John and others > > The ATSB has a system for classifying accidents and incidents - see on their > web site http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx and > http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx#fn2 > - the latter identifies what the various levels of investigation involve in > terms of ATSB resources. > > Sport and recreational aviation accidents - even fatal ones - are almost > never accorded a classification higher than 4, which means that after the > recording of various factual information, the investigation is either carried > out with one or two ATSB investigators or may be referred to another agency. > In the case of a fatality this is often the police force in the State or > Territory where the accident occurred - either for potential crime > investigation or more likely for the Coroner to investigate. The > Police/Coroner will usually seek the assistance of the GFA in the case of a > gliding accident, but the GFA generally regards itself as under-resourced to > carry out aviation accident investigations, as no funding is provided from > Government sources to train and equip investigators.In any event the funding > provided by Government to the ATSB is such that most accidents are not > investigated in any level of detail, unless they involve passenger transport > operations in large or medium capacity aircraft. The days when ATSB > investigated sport aviation accidents to any greater extent than this ended > over 20 years ago, and are not likely to return. > > While gliding fatalities are investigated by TAIC in New Zealand, that is not > the case here, and the amount of knowledge gained from NZ investigations is > not significantly higher than here. > > A further factor that militates against the GFA conducting and publishing > accident reports is the fact that, unlike Government agencies, the > investigator may be held personally liable for the way findings are reported, > and challenged by relatives of the deceased or others who have suffered > personal or property loss, or by survivors of the event who may claim some > degree of negligence (read financial compensation for some assumed fault by > the GFA or its members) or defamation as a consequence of the reporting. > This has the potential to affect all of us, whereas an ATSB investigation is > rarely handled this way. Note that this is a fact in spite of the > acknowledged purpose of accident investigations being to prevent recurrences > and identify procedures or training that may assist in this goal: accident > investigators do not lay blame for occurrences (and sometimes it is hard to > read into their reports any reference to even obvious breaches of the law or > safe operating procedures). > > This is why we have to wait so long for a Coroner to produce a report before > we can make changes to the system, especially where training or procedure > changes are involved, or airworthiness actions. > > Wombat > > > On 25/04/2012 12:09 PM, john.mcfarlane wrote: >> >> I would have thought that this is a mandated reportable incident via the Fed >> Gov body delegated with that authority – ATSB. >> Will there be a formal report from the ATSB? >> From: [email protected] >> Sent: Monday, 23 April 2012 4:17 >> To: Discussion of issues relating to Soaring in Australia. >> <[email protected]> >> Subject: Re: [Aus-soaring] GFA Site/accident >> >> Re accident prevention, in this instance we will have to wait on the >> Coroner's report, which I would not expect any time soon. It may be able to >> pinpoint a problem, and if so we - that is the collective we - can then act. >> However I am not holding my breath on this one. >> Regards, >> Gary >> >> >> _______________________________________________ >> Aus-soaring mailing list >> [email protected] >> To check or change subscription details, visit: >> http://lists.internode.on.net/mailman/listinfo/aus-soaring > > > > _______________________________________________ > Aus-soaring mailing list > [email protected] > To check or change subscription details, visit: > http://lists.internode.on.net/mailman/listinfo/aus-soaring > _______________________________________________ > Aus-soaring mailing list > [email protected] > To check or change subscription details, visit: > http://lists.internode.on.net/mailman/listinfo/aus-soaring
_______________________________________________ Aus-soaring mailing list [email protected] To check or change subscription details, visit: http://lists.internode.on.net/mailman/listinfo/aus-soaring
