PC 9 Crash report

[GoneToTheCanner]

Hi all
It's a pity that it takes fatalities to make an organisation improve itself. Like a wise old Canadian human factors instructor once told a class of us mechs, "you might hate air law, but every rule that's in the books was written with dead men's blood". The institution learned from 248 and will do so again from 265. Personally, I'd regard having FTS with no active CO as a serious institutional mistake. It goes against the grain of hard-won experience.

regards
GttC

[hptmurphy]

As a newcomer to IMO I was kindly informed by a moderator that members of the Air Corps are not permitted to post here.

Officially...and thats DF policy that is not to say that members of the Aer Corp could actually post here but couldn't identify themselves.

Given the nature of the subject and given a lot of the details that would either corroborate or deny some of the comments made here would be exclusive to the Aer Corps it would be a dangerous time for any serving Aer Corps memeber to add to the debate something which might compromise their identity.

It has happen in the past with members and other branches of the DF.

If however former members or those who have additional information chose to post it is accepted that the post may be debated.

Should there be a 'agenda' or perceptions there of it is then the moderators place to either delete posts or lock down a thread.

Depending on what people are prepared to discuss or comment on the thread lives or dies a natural death.

If there are aspects of the thread you don't like its should be brought to the attention of a Mod who will act accordingly.

Yes this one is getting close to the bone but given the nature of the subject and how there was an attempt to keep it out of the public domain I think the discussion will be quite biased at attempting to highlight failures that led to the incident, as it has already been suggested that incidents involving fatalities and loss of aircraft in the AC may be above an acceptable level.

[Tadpole]

Loki,
I am sorry you feel this way but I can understand sensitivities around this subject. However from what I have seen on this thread in particular the discussion has revolved around facts substantiated in the crash report and publicly known facts on accidents and incidents in the Air Corps. This has at some stages been evaluated against the experience of ex Air Corps personnel who have moved on to civil operations and seen the operation from both sides.
While it may be an official no no for AC personnel to come on here they do. Before you depart, please just read some of the threads and see how robust some of the threads can get. Both sides are here in force and it's never one sided.

[DeV]

Nothing to do with any level of management within the AC was found to be a cause or contributing factor to the accident.

There were details about management in the findings.

I have read the report. It's your reply I don't understand?

3. Conclusions
(a) Findings
19. OC FTS was not qualified on the PC-9(M). The Investigation considers that this situation was
not conducive to optimum oversight of FTS.
20. Self-authorisation by the Instructor (CFI) was found to be the norm in FTS. This reduced
supervisory oversight and was not in accordance with good safety practice.
21. Visibility was not assessed in the Sortie Risk Assessment Form.
22. The level and scope of the audits of FTS was limited.

(b) Probable Cause
Controlled Flight Into Terrain (CFIT) attributable to Spatial Disorientation due to a Somatogravic
Illusion following the loss of Situational Awareness.

(c) Contributory Factors
1. Continued flight towards high terrain in deteriorating weather.
2. Very changeable weather conditions.
3. High speed in a high terrain area while visibility was reduced.

which at least in part would have been negated by a pilot maintaining proficiency as per IAC regulations. Now lets look at this from the report perspective:

1. Lack of proper oversight: Was the OC aware that pilots were not maintaining proficiency? Could he as he wasn't type rated?
2. Lack of direction to crews: While the regs say you will maintain proficiency does the manual outline currency requirements such as once a month, once every 6 months? If not why not, whats the point of a requirement for proficiency without a currency requirement? If it did have a currency requirement it is obvious from the report that no currency was kept.
3. Problems within the FSS system: If the FSS system and self auditing system was properly working it would have noted that pilots were not carrying out proficiency in something as basic as emergency procedures.
4. No external auditing: Again, would an external auditor have noted that basic emergency procedure weren't being practiced.

So, we have an aircraft that gets to 34 degrees nose up at 1700' in 1500' terrain. All that was required was to maintain wings level, nose where it is and climb. This didn't happen due to disorientation, a known potential result of a low level abort. Now:

Would currency and proficiency in low level aborts have saved this crew?
Why was the required proficiency not carried out?
Still think management have nothing to answer for?

I would point you to Finding number 3 - 3.

The flight crew were appropriately qualified with valid IAC ratings.

As a newcomer to IMO I was kindly informed by a moderator that members of the Air Corps are not permitted to post here.Having read all the posts on this thread there have been no substantive posts (citing actual current policy and procedures) that counter any of the claims being made about/against the air corps. Fron this I can assume that members of the Air Corps are respecting the order not to post here. With that in mind anyone can make any claim "air corps pilots are only trained to turn left" and nobody can prove them wrong with anything other than additional conjecture. This is the basic flaw with an online "debate", especially regarding such serious matters... it is inherently one sided and in favour of those so called 'vested interests' (if there are any here) who can start a post with some obligatory hand wringing before getting the knife in.

Your correct! However that is how discipline is maintained in a military organisation.

Loki,
I am sorry you feel this way but I can understand sensitivities around this subject. However from what I have seen on this thread in particular the discussion has revolved around facts substantiated in the crash report and publicly known facts on accidents and incidents in the Air Corps. This has at some stages been evaluated against the experience of ex Air Corps personnel who have moved on to civil operations and seen the operation from both sides.
While it may be an official no no for AC personnel to come on here they do. Before you depart, please just read some of the threads and see how robust some of the threads can get. Both sides are here in force and it's never one sided.

[Tadpole]

I would point you to Finding number 3 - 3.
The flight crew were appropriately qualified with valid IAC ratings.

Yet as already pointed out the emergency procedure that was initiated by the instructor had cleared the terrain and if held would have saved the crew and aircraft. However, the IAC DID NOT practice low level aborts in flight, despite their own manual requiring proficiency, leaving the pilots inexperienced in and open to the IAC documented disorientation effects of the low level abort. Who is responsible for that?
While finding 3-3 of the report undoubtedly set off this chain off events it was loss of control due to disorientation that finally led to the aircraft impacting the surrounding terrain.

While the crew certainly made poor choices on the day I am afraid when it comes to the overall management responsibility you are sticking your head in the sand.

[hptmurphy]

Yet as already pointed out the emergency procedure that was initiated by the instructor had cleared the terrain and if held would have saved the crew and aircraft. However, the IAC DID NOT practice low level aborts in flight, despite their own manual requiring proficiency, leaving the pilots inexperienced in and open to the IAC documented disorientation effects of the low level abort. Who is responsible for that?

Management of course, however if it had not be the case to practice this type of drill with other types perhaps the whole scenario had been overlooked, this would suggest that either they were totally ignorant of such instances over the entire history of the AC or they chose to ignore it?

The other point being given the relative recent introduction of the aircraft had a proper evaluation been carried out by those responsible for developing manuals drills etc, and did those again responsible have sufficient experience on the type to be able to develop these things?

I'm sure the manufacturer had addressed all such scenarios during development but did the AC include the manufacturers recommendations in operation and training for the AC?

[DeV]

I say again according to the completely independent AAIU report - The flight crew were appropriately qualified with valid IAC ratings.

[Tadpole]

Management of course, however if it had not be the case to practice this type of drill with other types perhaps the whole scenario had been overlooked, this would suggest that either they were totally ignorant of such instances over the entire history of the AC or they chose to ignore it?

Don't see how they could be considered to be ignorant of the drill when they wrote it in their own manual and even stated that crews would be proficient in it. So that only leaves two possibilities: 1. They deliberately ignored it or 2. they accidentally ignored it. Either way its a serious indictment of the management of this operation.

The other point being given the relative recent introduction of the aircraft had a proper evaluation been carried out by those responsible for developing manuals drills etc, and did those again responsible have sufficient experience on the type to be able to develop these things?

Again, the procedure that could have saved this crew is in the IACs own manual, they just weren't proficient in it.
WRT other drills such as slow flight in poor weather it is certainly something that was taught in the SF260 while the high level return option was also taught and briefed in the Fouga for nav exs. Dont know how or if these translated into the PC9 but the basics were there long before the PC9 op.

[Tadpole]

I say again according to the completely independent AAIU report - The flight crew were appropriately qualified with valid IAC ratings.

And the same independent AAIU report also states that the IAC up until the time of the accident performed no in flight low level abort training.
The excerpt from the IAC PC 9 manual, in the same independent AAIU report, also states the crews will be proficient in the maneuver. Funny old thing, they are now practicing this maneuver.

Also in the independent AAIU report " The discipline of staying on and following instruments is fundamental to controlled flight in
IMC. The indications are that this did not happen following the final pitch up, probably due to
overwhelming sensations causing him to disbelieve his instruments.By the time ground was seen
there was insufficient height to recover"

Now where have we read in the same independent AAIU report about a maneuver that can cause serious disorientation? A Maneuver that pilots would 'maintain proficiency' in? A maneuver that they didn't 'maintain proficiency' in.

So were they rated on type: Yes
Were they IFR rated: Yes
Were they proficient in the emergency low level abort that ultimately could have saved them: No.

[DeV]

The AAIU didn't find that to be a contributing factor in the accident!

[hptmurphy]

Don't see how they could be considered to be ignorant of the drill when they wrote it in their own manual and even stated that crews would be proficient in it. So that only leaves two possibilities: 1. They deliberately ignored it or 2. they accidentally ignored it. Either way its a serious indictment of the management of this operation.

OK.........They as in the pair involved...which leads to the next stage. Who is ultimately responsible for everything related to safe around the operation?

No need for an answer but you see where its going.

Again, the procedure that could have saved this crew is in the IACs own manual, they just weren't proficient in it.
WRT other drills such as slow flight in poor weather it is certainly something that was taught in the SF260 while the high level return option was also taught and briefed in the Fouga for nav exs. Dont know how or if these translated into the PC9 but the basics were there long before the PC9 op.

Why would a training captain not be proficient in something that could get himself out of trouble and if he wasn't why wasn't it discovered during an evaluation, of course assuming there is an evaluation process.?

I'm getting a bigger picture the image of which I don't like.

Thanks for the input

Does at all finish with the AAIU report or is there dues process such as a court of enquiry?

[Tadpole]

OK.........They as in the pair involved...which leads to the next stage. Who is ultimately responsible for everything related to safe around the operation?

No need for an answer but you see where its going

Sorry HPT, when I said 'they' I had meant the Air Corps as it is their manual and it was the IAC that wrote it. However, you are correct that the crew should have been aware of the potential problems and proficiency requirements of the low level abort as it was in the manual for an operation they were involved in. Unfortunately, if it was the cultural norm not to practice low level aborts then this crew wouldn't have done anything different.

[hptmurphy]

Sorry HPT, when I said 'they' I had meant the Air Corps as it is their manual and it was the IAC that wrote it. However, you are correct that the crew should have been aware of the potential problems and proficiency requirements of the low level abort as it was in the manual for an operation they were involved in. Unfortunately, if it was the cultural norm not to practice low level aborts then this crew wouldn't have done anything different.

Thanks for the clarification, I have to agree with you on your last point , but no one is going to admit to cultural norms that compromise safety.

[Tadpole]

The AAIU didn't find that to be a contributing factor in the accident!

OK, then perhaps you can explain to me which of the contributing factors outlined in the report (and below) lead to the actual "Spatial Disorientation due to a Somatogravic
Illusion"

(b) Probable Cause
Controlled Flight Into Terrain (CFIT) attributable to Spatial Disorientation due to a Somatogravic
Illusion following the loss of Situational Awareness.
(c) Contributory Factors
1. Continued flight towards high terrain in deteriorating weather.
2. Very changeable weather conditions.
3. High speed in a high terrain area while visibility was reduced

Again, back to the report, that I can see there is only one maneuver preformed during the flight that lead to the probable cause, spatial disorientation following the low level abort followed by Somatogravic Illusion caused by the -3g pushover. Both of which were the result of an attempt maneuver which the pilot wasn't proficient in.

Findings 13 and 14
13. The final turn ended with a rolling pitch-up into cloud when an Emergency Low Level Abort manoeuvre was probably commenced.The vigorous manoeuvring prior to this made the onset of spatial disorientation more likely.
14. The aircraft then commenced a push-over, ultimately reaching -3G, which most likely led to somatogravic sensations causing a False Climb and Inversion Illusion

[Charlie252]

I say again according to the completely independent AAIU report - The flight crew were appropriately qualified with valid IAC ratings.

I make the following statements without any inference to the Individuals involved in the accident, however the report states "The flight crew were appropriately qualified with valid IAC ratings" so maybe its worthwhile to investigate the Organization and assess its perception of standards and qualification..

Do AC pilots have a license? Do they have a document that lists there level of training, there currency and there type qualification, or even there medical status??

What are the periodic currency requirements, what items are checked each currency period and what are the minimum standards required, if a pilot is found to be out of currency or not meeting the required standard what are the processes to train the individual to standard.

Who conducts the checks and finally who "checks the checker"?

Is still not the Case that the AC is the operator and the regulator???

[GoneToTheCanner]

Hi all,
It's not that long ago when AC pilots had to remind them upstairs when their IR renewals were due. I saw several letters of that nature in my time. In the airline system, the pilots licensing and medical renewal dates are tracked by computer and is printed for them when they book in for a flight, yet they are, by law, held responsible for their personal licensing. One other point about this report is that the names of the investigation team were not published, which is not normal practise for the AAIU.

regards
GttC

[billybob]

The Sunday Times today are running an article entitled" Department of Defence fight claim over cadets death in crash"
Link to follow, however in my opinion it does not read very well in reference to DOD stance. Cadet Jevins father is quoted within the article in relation to his sons actions during the last 5 minutes of the flight.


Moved by Turkey; wrong thread.

[Goldie fish]

http://www.rte.ie/news/2013/0304/372...crash-inquiry/

Interesting turn of events.

[Meatbomb]

Would the findings of the inquiry be made public?

[GoneToTheCanner]

This is the usual cynical shit from Fianna Fail, they don't give a rat's ass about the families of the deceased except to use this opportunity to score political points. Reopening an investigation won't bring back the dead and it makes a mockery of the independence of the AAIU if politicians feel that they can interfere into things they know nothing about.

regards
GttC

[Goldie fish]

They aren't talking about the AAIU. They are talking about the Internal Air Corps Inquiry, which seems to have picked and chosen the AAIU findings to suit themselves, and certain peoples careers.

[Tadpole]

They are talking about the Internal Air Corps Inquiry, which seems to have picked and chosen the AAIU findings to suit themselves, and certain peoples careers.

Nobodys fault, shit happens, shuffle a few deckchairs and pray it doesn't happen again....but it will.
If history has taught us anything lack of proper accountability by 'Managers' just lets the same old scenarios play out again and again and again. Until somebody has a genuine fear of personal loss the extra work to sort shit out just isn't worth the hassle. Never has been.

[DeV]

Giving that the Court of Inquiry is a closed court we don't know what they are!

[Tadpole]

Giving that the Court of Inquiry is a closed court we don't know what they are!

Do we need to? Considering that the family of one of the pilots has had to go down a political route says it all. Nobody will be found guilty of any wrong doing, nobody will be held accountable and therefore nothing will change.

Accidents aren't for hiding, they are for learning from.

[Tadpole]

Was't it the instructors fault. ?

Ultimately the final decisions, like on any flight, were made by the aircraft commander but rarely does an accident start and end on the final flight.
For example, the final dive was consistent with disorientation caused by the low level abort. This possibility was not only well known about but also written about in the IACs PC-9 operations manual. It was also stated that because of this pilots would be trained and practiced in the low level abort but up to the date of the accident no crews had practiced the low level abort and therefore had not experienced its debilitating effects, despite it being in the operations manual. So:

1. Who decided that low level aborts didn't need to be practiced?
2. Who decided to ignore the PC-9 operations manual?
3. Where was the oversight to ensure the operations manual was being followed and enforced internal to the unit and above unit level?

Unfortunately on the day in question, irrespective of what decisions the commander did or didn't make to begin with, they started and almost successfully pulled off a low level abort (they cleared the surrounding terrain before descending again) before succumbing to a phenomenon that was known to cause disorientation in a manoeuvre that was never practiced. As far as I'm concerned there are questions to be answered beyond the crew on the flight. Questions that, lets be honest, will never be answered.