Announcement

Collapse
No announcement yet.

PC 9 Crash report

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • #76
    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

    Comment


    • #77
      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.

      Comment


      • #78
        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.

        Comment


        • #79
          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; 6 March 2013, 12:44.

          Comment


          • #80
            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!

            Comment


            • #81
              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; 6 March 2013, 13:51.

              Comment


              • #82
                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.

                Comment


                • #83
                  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

                  Comment


                  • #84
                    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?

                    Comment


                    • #85
                      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

                      Comment


                      • #86
                        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.
                        Covid 19 is not over ....it's still very real..Hand Hygiene, Social Distancing and Masks.. keep safe

                        Comment


                        • #87
                          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; 7 March 2013, 01:05.

                          Comment


                          • #88
                            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.

                            Comment


                            • #89
                              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; 7 March 2013, 01:40.

                              Comment


                              • #90
                                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.

                                Comment

                                Working...
                                X