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  1. #76
    Moderator DeV's Avatar
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    Quote Originally Posted by Tadpole View Post
    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.
    While you are correct (it is in the AAIU report), it was not found to be a contributing factor

  2. #77
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    Quote Originally Posted by DeV View Post
    While you are correct (it is in the AAIU report), it was not found to be a contributing factor
    Sorry Dev, you have lost me . What do you mean exactly? What was not found to be a contributing factor.

    Interesting questions you have asked tadpole.

  3. #78
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    While you are correct (it is in the AAIU report), it was not found to be a contributing factor
    Dev, the crash was finally caused by crew disorientation, is that correct?
    The disorientation was a known side effect of the type of low level abort that the crew attempted, is that correct?
    This effect and the training crews would receive so that they were familiar with it are fully compiled within the IACs PC-9 manual, is that correct?
    IAC crews up until the time of the accident never actually trained in low level aborts, is that correct?

    If this was found to be a contributing factor by the AAIU or not the fact is the crew died as a result of a side effect from a manoeuvre they carried out. A manoeuvre that under their own operations manual the crew should have been trained for and weren't.
    Why weren't they?
    Who made the decision not to?
    Was it just lax training / currency procedures within the units?
    Was it lack of oversight?
    Was it indicative of a wider problem?

    Surely questions worth asking. The problem is if you don't ask the questions, only the ones you want to answer or if you do and find nobody personally accountable then the same situation is going to play itself out again and again. Simple as that.

  4. #79
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    Unfortunately Tadpole the reality in aviation is that a lot of training regimes are reactionary. In many cases it takes an incident or accident for something to be incorporated into a training regime, due to the rarity of an event.

    Our own training often incorporates real life events, for example after Capt Sullenberger went for a swim in the Hudson within a couple of months I was practicing dual engine failure due to multiple bird strikes followed by ditching off Portmarnock beach in the simulator. After the Air France crash in the south Atlantic we were doing upset recoveries at high altitude.

    The question of whether or not an instrument qualified instructor should have been able to transition to instrument flight in those circumstances is a valid one and whether or not simulator training would have helped the subsequent and slightly inexplicable spatial disorientation of such an experienced pilot is another.

    Actually recreating this event in the AC simulator for training, that would be quite difficult in a fixed based simulator, ie it doesn't move.

    The majority of aviation accidents could have been prevented with training. However,it often takes an accident to occur for phenomena to be seen as a threat. Some things are so obscure and often others are assumed to already be well within the capability of the pilot. Something you would have to assume in this case.

    In the aviation community and indeed in the broader sense, not one person among us goes to work in the morning with the intention of not returning ourselves and those under our care home safely to our families that evening. Those to whom we report endeavour to give us the tools to do just that.

    There was nothing intentional here and I fear that the chip on your shoulder for all things Air Corps clouds your judgement in Air Corps matters(as it often does).

    All we can hope for in this incidence is that the Air Corps have reacted to this the same way the wider aviation community does in time of loss: implement training and procedures to eliminate the threat of recurrence.

    Some accidents are preventable. Some accidents are caused by simply turning into the wrong valley. Some accidents are sadly just as they appear, pilot error.
    Last edited by Jetjock; 6th March 2013 at 11:44.

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  6. #80
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    Quote Originally Posted by Tadpole View Post
    Dev, the crash was finally caused by crew disorientation, is that correct?
    The disorientation was a known side effect of the type of low level abort that the crew attempted, is that correct?
    This effect and the training crews would receive so that they were familiar with it are fully compiled within the IACs PC-9 manual, is that correct?
    IAC crews up until the time of the accident never actually trained in low level aborts, is that correct?
    Correct on all but it says "FTS did not conduct in-flight training" - it doesn't say did not conduct training (it may have been done in simulators) - the report doesn't say.

    The manual doesn't say if the "proficiency" should be sim or flight based.

    If this was found to be a contributing factor by the AAIU or not the fact is the crew died as a result of a side effect from a manoeuvre they carried out. A manoeuvre that under their own operations manual the crew should have been trained for and weren't.
    Why weren't they?
    Who made the decision not to?
    Was it just lax training / currency procedures within the units?
    Was it lack of oversight?
    Was it indicative of a wider problem?

    Surely questions worth asking. The problem is if you don't ask the questions, only the ones you want to answer or if you do and find nobody personally accountable then the same situation is going to play itself out again and again. Simple as that.
    My point is it wasn't found to be a contributing factor!

    The only mention it that was probably attempted by the instructor.

    It is not mentioned by the experts as a contributing factor or a safety recommendation!

  7. #81
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    Jetjock,
    I agree with everything you say except my point isn't actually about the training, my point is about the ability of an organisation to conduct its operations as it lays down within its own manuals and when it doesn't where does the buck stop to prevent it happening again?
    Yes all training, quite rightly, is based on the lessons learnt from past accidents, but what about the organisation what is it learning? Have a look at organisations that have external oversight and control, does a simple internal organisational audit followed by deck chair shuffling suffice or is it rigorously investigated by an external source and forced to make changes weather it wants to or not?

    Correct on all but it says "FTS did not conduct in-flight training" - it doesn't say did not conduct training (it may have been done in simulators) - the report doesn't say.

    The manual doesn't say if the "proficiency" should be sim or flight based.
    Oh come on Dev, a bit of common sense please. If the primary danger with a low level abort is disorientation caused by manoeuvring effects within the pilots senses, which cannot be recreated in a fixed base simulator, then it can only and should only be performed in an actual aircraft. ie student under the hood and instructor operating as safety pilot. If the IAC deemed it suitable to train for something in a sim that cannot be recreated in the sim then that begs even more questions about the competence of the training syllabus.

    It is not mentioned by the experts as a contributing factor or a safety recommendation!
    So is your point that even though there is a very strong connection because its not in a report its not worth asking these questions for the safety of future crews?
    Last edited by Tadpole; 6th March 2013 at 12:51.

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  9. #82
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    I don't think external oversight is a factor. It is in no one's interest to have a hull loss. Airlines often develop training program's due to industry trends, not at the behest of national regulators.

    It was probably more akin to priorisation of training tasks in what was maybe an already packed syllabus. Often in all branches of aviation a trend needs to develop in order for certain items to gain in priority.

    You can be guaranteed one thing, it's high on the list now.

    Regarding the loss of situational awareness, the primary event in that regard was the overall loss ie turning into the wrong valley. I regard the subsequent loss of awareness in the recovery as rather surprising, something I'm sure the brass may have also regarded as unlikely when devising the active training programme. The crash was in 2009, five years into PC-9 operations. Long enough but still relative to actual flying hours not that much. The instructor had 865 hours on type, still not much considering that much of that would have been hands off. However, the recovery procedure is still the same as it is in any aircraft: firewall the throttle and pitch up to max climb angle and hold it there until above MSA. I suspect the issue here may have been as simple as looking through the HUD rather than at it.

    My overall point is that unfortunately some training is prioritised over others based on perceived threat levels of an event. It sometimes takes an event for that manoeuvre to be pushed up the list of priorities. This I fear is one of those incidences.

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  11. #83
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    Quote Originally Posted by Tadpole View Post
    Oh come on Dev, a bit of common sense please. If the primary danger with a low level abort is disorientation caused by manoeuvring effects within the pilots senses, which cannot be recreated in a fixed base simulator, then it can only and should only be performed in an actual aircraft. ie student under the hood and instructor operating as safety pilot. If the IAC deemed it suitable to train for something in a sim that cannot be recreated in the sim then that begs even more questions about the competence of the training syllabus.
    The manual says it is a "risky" procedure!

    Don't forget they were both under the hood due to the weather, the instructor was the most experienced IAC PC-9 pilot.

    Also page 52 says the low level abort couldn't be followed due to terrain!
    So is your point that even though there is a very strong connection because its not in a report its not worth asking these questions for the safety of future crews?
    What from it!!

    But it isn't specific to this accident!!

    First and foremost no operation can take out all risk but it must be managed, both top down and bottom up

  12. #84
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    Long time lurker here, not a military man but have a keen interest, also a PPL for 15 years so I'd like to think I can join ye're level of discussion.

    If I'm honest, these latest revelations are extremely worrying, and arguing about technicalities of the report is totally missing the point. What I see here is a total unwillingness to change, an un willingness to discipline and an unwillingness to make unpopular decisions. I say this because a few thing is the latest articles set off alarm bells for me.

    Lets start with this one:
    Mr O Fearghaíl said that vital evidence from the inquest was overlooked
    A quick google of articles from the the time of the inquest, and I'd be confident I could make a good guess at what evidence Mr O Feargháil is talking about, One article has this gem.
    Under cross-examination by Mr Jevens, the brigadier general also agreed there had been no flight safety audits in the training school between 2004 and 2009..."If I’d known about it, it would have been acted upon, absolutely"
    That is totally inexcusable. Surely these safety audits would have revealed the low level abort training was not taking place? In my own opinion, whoever's responsibility it was to make sure audit(s) were done should be brought up on a charge in front of a military court. Maybe I'm wrong but to me this looks like a case of somebody not bothering their hole to do their job for 5 years. Not acceptable in anyway. When FF say "key personnel were not interviewed in the inquiry". I would hope the person responsible for safety audits wasn't one of these.

    Just on what is posted above. Somebody as it was case of turning up the wrong valley. I skimmed through the aaiu report and found this
    the planned exercise did not involve low-level navigation

    Surely then the aircraft should not have been flying down any valleys? Hence why the cadet asked to divert away from the area once it became clear that there were IMC conditions ahead?

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  14. #85
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    The reason I quote the report so much is that AFAIK it is the only report in the public domain, and there could be cases/inquiries ongoing which I'm sure no one here wants to effect.

    Link to that article??

    At the end of the day, there were only 2 people who know exactly what happened, and they may not even know.

    The AC lost an aircraft, an instructor and a cadet.
    Was it preventable? Who knows.
    Should all recommendations be acted on? Yes

  15. #86
    Commander in Chief hptmurphy's Avatar
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    Was it preventable? Who knows.
    It was preventable, but the root cause was deeper than the crew involved.

    While the captain of the flight may have had to make some descisions along the way that may have been questionable , in military flying as in all military operations the training and checks along the way have to scruitinized for all grades involved.

    In the last two most documented incidents in the Aircorps, the Dauphin at Tramore and this one, PIC descisions and most notably weather have featured prominantly.Though they are some years apart and involve dissimilar types on both occassions training deficits have been highlighted.

    Bigger review of operational training required methinks.
    Just visiting

  16. #87
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    Sometimes it's simply a case of the pilot f"%king up, and no amount of looking for someone or something to blame will change it.


    Fougas had a good record, did this mean all the systems in place were perfect.? I know of one flight were the crew hopped out at the end of it with nose bleeds.

    People are not 100% predictable.
    Last edited by sofa; 7th March 2013 at 00:05.

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  18. #88
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    Quote Originally Posted by sofa View Post
    Sometimes it's simply a case of the pilot f"%king up, and no amount of looking for someone or something to blame will change it.
    What a silly thing to say. The crew involved made decisions that ultimately resulted in a preventable accident, and RIP to them both. The route to that hillside started long before they strapped into their seats that day. There is a system failure that let them down. The AAIU report was kind to the AC IMO.
    All commercial Air Accident investigations trace contributory causes to training deficits or system failures. Sure crews made decisions or actions that sealed their fate but we can hardly say "oh, they fooked up and close the book" that's sweeping it under the rug in my book.

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  20. #89
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    I would disagree that this accident was absolutely preventable. However, the risk mitigation given by proper oversight and strict adherence to procedures was hugely lacking both at an individual and an organisational level.

    Oversight and continual checking brings with it an implied onus on the operating pilot to know and adhere to all procedures when operating an aircraft. The fact that it was as lax as it was is downright damning on the Air Corps and while it reduces the risks that an individual will go outside the boundaries as set down in black and white in the operations manual, it cannot totally eliminate bad decision making altogether. Human error can be minimised but never eradicated. In this case full oversight may not have influenced the decision not to abort that leg of the nav ex . It is impossible to say. Oversight alone does not make a crash caused by human error absolutely preventable.

    One would after all expect an experienced instructor to be absolutely profficient in the operations manual and I'm sure he was. Therefore a conscious or otherwise decision to step outside its boundaries cannot be accounted for. The absolute lack of CRM in the cockpit decision making needs to be looked at in sharp focus. The aviation world has moved in that sense and maybe the military needs to take note. The lack of an OFDM is also of note. The implementation of Operational Flight Data Monitoring has hugely advanced safety in the airline world. You simply do not step outside a preset range of boundaries. Big brother is watching..

    Regarding the low level abort, again it is a matter of perceived threat. It may have been perceived as low enough to be covered in the simulator. Hindsight is fantastic thing. The abort procedure is not at all a complicated one. It was inexplicably, to me anyway, not applied correctly. You can talk about somotagraphic illusion and the recognition of same but you cannot tell me the Air Corps PC9 singleton display pilot would not recognise its onset. The failure was simply not transitioning to instrument flight. A cardinal error at any experience level. Human error mind and probably attributable to the startle factor but human error all the same. It happens and no amount of oversight etc etc....

    Focussing primarily on a lack of in flight training for the abort manoeuvre may seem a worthwhile exercise but in effect it does nothing but mask the wider implications of the report.

    The organisational flaws are there for all to see, though it is impossible to say whether or not they had a direct influence decision making process that led to the crash. The lack of and lax nature of auditing is a primary example. I have suggested before that a former officer from an overseas air arm be employed at departmental level to conduct this. Without a shadow of a doubt an outside perspective is absolutely necessary, reporting to a Minister rather than a GOC.

    This (extremely comprehensive by any standards) crash report turned up flaws in the decision making and flaws in the organisation. These flaws needed to be aired and they need to be acted on.

    The cause however is and will sadly remain, human error. (There but for the grace of God, go I.)
    Last edited by Jetjock; 7th March 2013 at 00:40.

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  22. #90
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    JJ,
    All good points and in general I agree with you, however a couple of points:
    1. WRT to training priorities I fully understand what you are saying but firstly surely emergency procedures should take precedence over items such as formation, aerobatics and air gunnery. Secondly, prioritising training means that at some stage you actually do the training, even if its priority is low. The fact that training of an emergency procedure never took place isn't prioritising its negligence.
    2. I can under stand that a course can be full and training prioritised but point 1 still stands. Out side of that why wasn't the instructor trained? Somebody in the Don decided that the PC-9 fleet / instructors had enough time to do formation practices, flypasts and airshows but not emergency low level aborts as per the ops manual???????

    Who decided on the above? Is it not worth asking?

    The manual says it is a "risky" procedure!
    Made even risky, if not fatal by not practising the emergency procedure.

    Don't forget they were both under the hood due to the weather, the instructor was the most experienced IAC PC-9 pilot.
    The exact reason why it should have been practised under the hood and as the most experienced instructor he had never once completed a low level abort training in an actual aircraft. Doesn't that ask a question in your head?
    Also page 52 says the low level abort couldn't be followed due to terrain!
    As in a straight pitch up? No a standard low level abort couldn't because they were in a turn which reverted into a climb. However, fore armed is fore warned. A pilot experiencing the effects of a standard LLAB will learn very quickly to follow the instruments, rolling out of a turn in the climb is a little more difficult but no different. Now, put the same pilot with no prior experience of this condition into the same scenario and the likely result is exactly what happened. Lets not forget, they actually cleared the terrain!!

    What from it!!

    But it isn't specific to this accident!!

    First and foremost no operation can take out all risk but it must be managed, both top down and bottom up
    How can you possibly say that a crew who died from disorientation induced by an emergency procedure that they carried out but were never trained for, contrary to their own ops manual, has nothing to do with this accident!!

    What absolutely astounds me is the amount of people willing to blame this squarely on the crew to protect the 'Good Name' of the IAC when really the prize to be had is protecting the aircrew. If that means root and branch change then bloody well do it before more families are without sons and/or daughters.

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  24. #91
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    JJ,
    I just seen your latest reply while replying myself. I cannot agree more with what you have said. My only concern is that the IAC will change for a while then lapse back into the same old way of operations. Been there, done that.
    Unfortunately without a strong stick to their backs I personally doubt that this is the last crash, fatal or otherwise that we will see within the IAC under what should be benign operating conditions.

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  26. #92
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    Hi Tadpole,

    Hopefully having the report made public will help ensure that if recommendations are implemented, they will continue to be enforced.

    The practice of sweeping previous reports under the carpet, however damning, is a privilege not extended to civilian pilots. It robs the rest of us of a chance to learn from it and was a practice I abhorred. There is no national security interest served by the non publication of a report on the crash of a Cessna in a field in Co Offaly.

    Regarding the prioritisation of training for ceremonial duties over emergency procedures and who took that decision, it is absolutely a question worth asking. The report only specifies a lack of in flight training. Given the relative simplicity of the manoeuvre, it is easy to see simulator training being regarded as sufficient. With hindsight however....

    Worth noting that the organisational flaws highlighted here would have a serious impact on careers in other Air Arms. There was no obvious movement on that front here.

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  28. #93
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    Quote Originally Posted by Meatbomb View Post
    What a silly thing to say. The crew involved made decisions that ultimately resulted in a preventable accident, and RIP to them both. The route to that hillside started long before they strapped into their seats that day. There is a system failure that let them down. The AAIU report was kind to the AC IMO.
    All commercial Air Accident investigations trace contributory causes to training deficits or system failures. Sure crews made decisions or actions that sealed their fate but we can hardly say "oh, they fooked up and close the book" that's sweeping it under the rug in my book.
    Instructor overruled the trainee, and continued on the planned route.

    Instructor was well use to the physical sensations he was experiencing in the high nose up at speed. and was aware, in low vis that you work with your instruments

    and not your senses. So what went wrong with who or what,

    Sometimes it's not always the Dons fault.


    Pan Am KLM crash in Tenerife report went in to detail on the whole situation. But the very senior captain of the KLM aircraft disregarded his co pilot doubts

    and started the take off.
    Last edited by sofa; 7th March 2013 at 01:45.

  29. #94
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    Worth noting that the organisational flaws highlighted here would have a serious impact on careers in other Air Arms. There was no obvious movement on that front here.
    It didnt in 1999, it didnt in 2004 and it wont as a result of 2009.

    10 years, 7 fatalites, 4 hull losses, accountability................ZERO

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  31. #95
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    I'm going to restate what the report said, "in flight" training was not conducted, for whatever reason.

    An independent body, the IAAs AAIU, didn't say sim or equally no training was done. It also didn't find that the AC safety culture caused or contributed to the crash, but it does make safety recommendations about it, I assume with an aim to trying to help prevent something similar happening.

    I am merely stating fact as found by the AAIU, we can infer things from it but I don't think that is right.

  32. #96
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    Quote Originally Posted by DeV View Post
    I'm going to restate what the report said, "in flight" training was not conducted, for whatever reason.

    An independent body, the IAAs AAIU, didn't say sim or equally no training was done. It also didn't find that the AC safety culture caused or contributed to the crash, but it does make safety recommendations about it, I assume with an aim to trying to help prevent something similar happening.

    I am merely stating fact as found by the AAIU, we can infer things from it but I don't think that is right.
    I think it might be worthwhile to consider a similar situation involving a commercial operator:

    The commercial operator will have an operations manual part D in which all training requirements for its crews are outlined, it will also detail the annual minimum requirements required for each crew to continue to operate the aircraft, it will detail the minimum standards and the actions to be taken should a crew not reach that standard. This manual will have been approved by the independent regulator. The training dept will be audited regularly, and the training requirements will be constantly under review. This will allow for proactive training to mitigate against an identified trend or to react to an incident either internally or externally.

    If, for whatever reason, the operator did not carry out the training as detailed in its own manual and the lack of that training was listed as a factor in an accident, there would be serious consequences. The post holders would most likely loose there jobs, in the case of a hull loss with loss of life they may also be personally liable, the operator may also face serious consequences up to and including suspension of its operating license until it can prove to the regulator that it can run its operations and its training in line with its approved Manuals.

    I think that's a reasonable interpretation of how a similar situation would play out in the commercial world, how does that compare to the AC?

    Is it appropriate that the operator and the regulator are in effect the same person?

    It is not good enough to blame the crew, it is not good enough to make glib statements such as "no crew sets out to crash" or "Shit Happens".
    There is a trend across all the incidents and accidents in the recent past, lessons were either learned in a very short term way or just ignored, either is not good enough. The organisation is culpable, but nobody carries the can there are no post holders, nobody is fired or held accountable..

    People do get promoted though!!

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    Just on the point of accountability. According to the FF story, key witnesses were not interviewed by the inquiry. I'm really curious as to who these people are. Why weren't they interviewed? Was it because they did something wrong and if that was 'officially' recorded disciplinary action would have to be taken? Who was on this board of inquiry, was it an "in house" job or was there civvy or general army presence making sure people weren't going easy on their mates? As taxpayers, I think we deserve answers to these questions.

    The thing is, those in the AC management don't seem to care when people die. That's plain to see after 99' and '04 and again in 09'. 265 showed no lessons were learned. Death is not enough to change the AC's culture. Peoples careers and reputations seem to be more important than people's lives. The only thing that will is discipline. Lack of discipline makes everybody think its OK to make mistakes, it isn't! A few years back a guy was fired for making a pretty harmless insult. Somebody's ego got hurt and a guy got fired. But 7 fatalities in 10 years and there is NO discipline. The place stinks of corruption and cover ups. The only thing that will stop negligence and arse covering is if perpetrators are named and shamed and lose their jobs.

    Of course it's not all management's fault, not by a long shot. I read the AAIU report when it was released and skimmed through it again this week. It is obvious the instructor took an unnecessary risk, made wrong decisions, broke rules and in the end wasn't capable of carrying out an emergency maneuver. There's no point watering that down for the sake of respecting the dead. Watering it down as I've said only makes other pilots think it's OK to make mistakes.

    In general the culture needs to change so that everyone knows that if you **** up, it will be known, there will be consequences and your mates wont be making it all go away.
    Last edited by Cesssenacavanman; 7th March 2013 at 15:19.

  34. #98
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    I think another, larger tragedy is that the details of what happened in 2004 were never made public, leading to a cloud of speculation and conjecture.
    If it were a PPL with a civvy C172 the AAIU would have provided a thorough analysis and there would be no doubt as to cause, and who, or what was at fault. I never understood why they did not publish in that case.

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    What was especially annoying about the non-publication of the Cessna crash was that it was witnessed by dozens of people (parachutists/pilots/other civvies) and filmed by many of them. It's not the only one that didn't make it to the public gaze, either. I wonder would an FoI search dig anything up?

    regards
    GttC

  37. #100
    Commander in Chief hptmurphy's Avatar
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    An independent body, the IAAs AAIU,
    I don't believe the AAIU is independent or far enough removed from the Air Corps to conduct objective equiries given its membership.

    It is obvious the instructor took an unnecessary risk, made wrong decisions, broke rules and in the end wasn't capable of carrying out an emergency maneuver.
    same can be said about Tramore and yest it continued to be overlooked from on high.The Air Corps are no longer to be trusted with self regulation when it comes to enforcing their own training regime.

    the pilot of the PC 9 was reprimanded for 'Hot Dogging' as the yanks would say, A recent comment made about the Capt of the Dauphin would suggest he was of a similar ilk and took unacceptable risks at times and overcommited to a flight that need not have taken place.

    Fundamental flaws if there are not checks and balances in place to monitor what instructors are teaching, and then the competency of these guys when they become operational.

    Who polices the police?

    certainly the Air Corps has proved to be incapable of policing its own people.
    Just visiting

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