Matt,
Some good stuff there. Another thing that can work against a pilot is getting
QNE and QNH confused - ie the pilot thinks he is higher than he actually is. I
suspect that this has been a contributing factor in at least a couple of
fatalities over the years.
In the Ararat case the glider had a working flarm. My understanding is that the
previous flights (on the day and earlier), were available, from the flarm after
the crash, but for some reason a trace could not be recovered for the fatal
flight. There is some conjecture that this may have been something inherent in
flarm. There is no reason to suspect that the electrics in the glider had not
been switched on for the last flight. For the sake of argument, let us assume
that the flarm was powered up about 2 minutes before the all-out call, and the
flight lasted 2 minutes, my maths says that there should have been about 60
recorded points (@ 4 sec intervals) available prior to impact, and maybe the
flarm should have kept logging after the impact?? It was noted that the glider
batteries were still in position and intact.
Anyone got any thoughts as to why nothing was recorded?
Gary
----- Original Message -----
From: Matt Gage
To: Discussion of issues relating to Soaring in Australia.
Sent: Thursday, April 26, 2012 9:34 AM
Subject: Re: [Aus-soaring] GFA Site/accident
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
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