Regardless of whether data can be retreived from a logger, the
information in a situation like this will be almost certainly be
worse than useless. A logger is not a "black box" of any kind.
A logger records position and altitude at some interval. In a Flarm
it's probably 4 seconds. Everything else is deduced from this
information. Therefore, you can figure out average climb or sink
rate between the fixes. You can figure out the average GROUND SPEED
between the fixes, but you can't get the airspeed. You can find out
whether the glider turned left or right, but you probably already know
that from witness reports.
It is likely if the glider spent time in a very nose down attitude,
that the ground speed between fixes will be small. This only means
that the two adjacent positions were close. It says nothing about
the airspeed. If there is no other information, the logger can't
tell you if the glider was stalled, spinning, in a spiral dive ior
executing an aerobatic manoeuvre under full control.
The bottom line is that logger traces don't work all that well in
accident investigation. What surprises me is that many otherwise
quite intelligent people are willing to draw all sorts of completely
unjustified conclusions from them.
If this trace can't be accessed I regard that as a good thing. It
will save some people from jumping to conclusions without a parachute.
Cheers
Tim
----- Original Message -----
From:"Discussion of issues relating to Soaring in Australia."
To:"Discussion of issues relating to Soaring in Australia."
Cc:
Sent:Thu, 26 Apr 2012 13:34:58 +1000
Subject:Re: [Aus-soaring] GFA Site/accident
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 [1] TO: Discussion of issues relating
to Soaring in Australia. [2] 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 , 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 [5] TO: Discussion of issues
relating to Soaring in Australia. [6] 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 [7]
and
http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx#fn2
[8]
- 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] [9]
SENT: Monday, 23 April 2012 4:17
TO: Discussion of issues relating to Soaring in Australia.
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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