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PC 9 Crash report

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  • #91
    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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    • #92
      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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      • #93
        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; 7 March 2013, 02:45.

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        • #94
          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

          Comment


          • #95
            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.

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            • #96
              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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              • #97
                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; 7 March 2013, 16:19.

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                • #98
                  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.


                  Catch-22 says they have a right to do anything we can't stop them from doing.

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                  • #99
                    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

                    Comment


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

                      Comment


                      • Originally posted by hptmurphy View Post
                        ........ and overcommited to a flight that need not have taken place.

                        ........
                        I could never comprhend why a D class lifeboat which had no radar was sent/went to look for the overdue boat in fog and promptly became part of the problem itself.

                        Comment


                        • Originally posted by danno View Post
                          I could never comprhend why a D class lifeboat which had no radar was sent/went to look for the overdue boat in fog and promptly became part of the problem itself.
                          On a small point, was an Atlantic 75 ILB. Equipped with moving map GPS. Unfortunately this gave up on the night.

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                          • The AAIU didn't have a problem slating the AC in the Tramore report!

                            Any way, as provided for in EU regulations, it isn't the AAIU's job to apportion blame or liability, merely to determine the circumstances and causes.

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                            • Htmurphy, in relation to your last point, you could be right. Irish Times have a bit more on this, does not read good at all.

                              Last edited by Helihead; 8 March 2013, 09:31.

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                              • Hi all,
                                Firstly, the AAIU are not part of the IAA. They operate under the Dept of Transport. They are very, very independent and very neutral. With regard to the lack of a suitable "authorisor", for PC-9 operations, the AC left themselves open and that opening should not have existed. The entire organisation had a shakedown after the 248 crash yet gaps and failures were allowed to creep in or continue to exist, because you have a strict hierarchy that rarely listens to any inmate who is not an Officer. A lot of policy and doctrine was created on the fly and the organisation has routinely taken bits and pieces from lots of sources and cobbled them together to make it's own manuals, which is half-arsed at the best of times. This wasn't only for pilot training, either. It was normal for technician training and for other specialities, to be substandard and below industry par. Post qualification training for aircraft techs was very haphazard, often ad-hoc and conducted on the fly and not documented or based on manuals or even carried out on an annual basis.

                                regards
                                GttC

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