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billybob
24th January 2012, 10:19
http://www.aaiu.ie/AAIUviewitem.asp?id=13426&lang=ENG&loc=1652

billybob
24th January 2012, 11:25
All this discussion on IAC involvement in HEMS should be stopped straight away. Read the PC 9 crash report.

morpheus
24th January 2012, 11:34
All this discussion on IAC involvement in HEMS should be stopped straight away. Read the PC 9 crash report.
WTF do you mean?

billybob
24th January 2012, 12:13
HEMS is a highy regulated operation that is overseen and audited by the external authority.
Please read the report in full and then consider IAC involvment in a role that is civil and regulated by external independent authority.

Bravo20
24th January 2012, 12:26
MOD: I'm sure that people don't need to be reminded that two people died in this incident. They have family and friends some of whom read this site. Please out of respect consider your comments carefully before posting.

morpheus
24th January 2012, 16:36
I thought billybobs comment regarding the pc9 crash was unfounded http://forum.irishmilitaryonline.com/showthread.php?19865-Air-Corps-air-ambulance&p=361354&viewfull=1#post361354
Having looked back at most of his AC related posts however I'm not surprised as it generally reflects his overall opinion of the IAC and is probably representative of his perception of their taking on "civvie" or private industry roles such as the air ambulance. everyone is entitled to an opinion, but that particular comment was just a tad sensationalised.

Aidan
24th January 2012, 17:02
that particular comment was just a tad sensationalised.

And inaccurate, oportunistic and deeply insensitive.

billybob
24th January 2012, 17:07
MOD. Im actually with Jet Jock on this. Ive made a point and Jet Jock does not see/ agree. Thats what this forum is about.

Jet Jock my point is self auditing has been highlighted within the PC 9 report and has been deemed inadquate.

The auditors were members of the IAC. While there can be a tacit acceptance from within an
organisation of the status quo, nevertheless an objective overview is required from safety auditors in
order to identify hazards and threats to safety.
It is also noted that no FSS audits were provided to the Investigation between 2004 and 2009. The
Investigation believes that this level of monitoring is inadequate and recommends that the IAC
should review the effectiveness of the FSS auditing processes.
The Investigation believes that all aspects of FTS functionality should be included in the FSS audit
process and that an external input to the audit process is recommended.


Here is the initial recommendation from the Dauphin crash report about the establishment of FSS.

The Department of Defence should establish, as a matter of urgency, a full-time fully-resourced Air Safety Office in the Air Corps, to be headed up by a Flying Officer of Lieutenant Colonel rank. This issue has already been the subject of a similar recommendation in the February 1998 Price Waterhouse Report.

Here is the PC 9 recommendation about SMS of which FSS is one of the main components.

GOC AC should review the operation of the Safety Management System within the IAC,
including the auditing process, and should consider an external input
.
I agree that the military are exempt to complying with civil rules and thats fine as long as they are carrying out military roles. Once the IAC become involved in purely civil roles involving civilian personal as part of the crew civil rules should apply . However can you really see the IAC agreeing to an IAA auditor showing up and carrying out a safety compliance audit as set out in JAR OPS.

Helihead
24th January 2012, 17:21
I have read the report and have taken a good look at the conclusions. It's all there in black and White. Lessons that should have been learned from previous accidents were not. SOP's are mentioned , CRM gets a look in, safe practises ( lack of) gets a mention, failings within the organisation, its all there. Listening to RTE earlier today the IAC said they accepted the report in its entirety, which is telling in itself. Does that mean all recommendations will now be acted on and implemented.

hptmurphy
24th January 2012, 20:28
It is not the purpose of any such accident investigation and the associated
investigation report to apportion blame or liability.


I think that about sums it up, read it ,form your own opinions,given the job in question accidents do happen, thankfully at a very low rate.

Maybe something will be learned to save someone else the grief these families have been through.

Rest In Peace.

jack nastyface
24th January 2012, 20:54
I think that about sums it up, read it ,form your own opinions,given the job in question accidents do happen, thankfully at a very low rate.

Maybe something will be learned to save someone else the grief these families have been through.

Rest In Peace.

Rest in Peace lads. Given the size of the Corps, i would say accidents and unfortunataly deaths are quiet high over the years. And hopefully something will be learned at last. My heart go's out to all bereaved.

danno
25th January 2012, 20:53
The AC is not the only org to ever have come under the spotlamp from the AAIU.Other orgs have had their knuckles rapped by the AAIU and this has not been confined to aero orgs.Let him who hasnt ....etc.

Charlie252
26th January 2012, 17:43
Very Sad reading the report, I had trouble sleeping, mulling over the same old problems throughout the Corps. I am astonished that FTS had gone the way of every other flying unit in Bal, that is with postholders that are either double or tripple jobbing and/or, who are not even type rated on the units aircraft. This problem has been a major issue throughout the organization for many years.
Most squadrons were like ghost towns with the Pilots only being present to sign out the aircraft for a mission and spending the rest of there time in there “real” job somewhere else on the base. Remember you are an officer first and a pilot second! In my experience this meant that squadrons operated at the lower end of the aircrafts capabilities and the functioning of the squadron as an operational/training environment for young pilots was very much reduced compared to how it should be. That is with pilots spending time planning missions, passing on experience’s, developing operational ideas and refining SOP’s plus the hundreds of intangibles that are present in a fully functioning squadron with a full compliment of Pilots.
When I went through BFTS the OC was the Boss he was present every day he wrote the flying detail and he did the 50Hr and Final Handling checks, as a result for the instructors at least, the unit operated like a proper squadron.

It is shocking given the higher risk profile of operating high performance single engine aircraft in a training environment that AC management did not deem it important to have a full time OC but had let the role become diluted.

I have nothing but the height of respect for the deceased instructor and immense sadness for the cadet, I also greatly respect the individual who was the postholder, who I am sure, was fully employed on the Lear.

I lay the blame fully at the door of AC management who for years have, half run the Corps and have never fully engaged with the realities of running a modern aviation organization, this malaise is fully manifested in the Too many accidents and incidents and the lack of any development of the Air Corps roles or capabilities. Its current difficult position in which it lacks focus or indeed any meaningful role means its future is actually in doubt.

Turkey
26th January 2012, 18:31
Remember you are an officer first and a pilot second!

Two interesting points here , I think. I belive that as a matter of urgency the officer/ pilot suitation be changed, so that pilots can focus entirely on the job in hand, flying aircrafts of this type in this manner is dangerous, but is essential if one is going to even pay lip service of it being any kind of air arm that is of use to the armed forces of this country.


I lay the blame fully at the door of AC management who for years have, half run the Corps and have never fully engaged with the realities of running a modern aviation organization, this malaise is fully manifested in the Too many accidents and incidents and the lack of any development of the Air Corps roles or capabilities. Its current difficult position in which it lacks focus or indeed any meaningful role means its future is actually in doubt.

I have been studying the Irish Air Corps as a Military organization for many years now, and I find that I have to fully aggree with Charlie252 on this. It is high time for an outside audit, but who can be trusted to carry it out, I do not believe it can be safely given to any civillian department, I think that the Air Corps will have to be judged by military organizations that have a proven record, in both peace or wartime. I accept that people may believe that it smacks of serious overkill, I nominate either the Royal Navy Fleet Air Arm[while it still exists], or the United States Navy. as in my opinion they represent the best military avaition providers of the english speaking world.

In the past 13 years the Air Corps have lost 7 aircrew in 3 different accidents, May they rest in peace.

Pure Hover
26th January 2012, 20:33
Like all accident reports it makes chilling and very sobering reading and for all those on the forum without an axe to grind or vested interest and who've actually taken the time to read the report in its entirity it forms the basis for comment and informed discussion on the inherent dangers and risks involved with aviation particularly in relation to SD and Somotogravic Illusion.
The research on the subject, well summarised in the report is extensive and grabs the attention. According to Newman (2007) in App D of the report "Spatial disorientation is a very common problem.....studies show that SD accounts for some 6 per cent to 32 per cent of major accidents and some 15 to 69 per cent of fatal accidents". He further asserts "It has been reported that for a given pilot, the career incidence of SD is in the order of 100 per cent....In other words, if a pilot flies long enough as a career or even a hobby there is almost no chance that he/she will escape experiencing at least one episode of SD. Looked at another way, pilots can be considered to be in one of two groups: those who have been disorientated, and those who will"

I'm certainly not in the category of those waiting to experience this phenomenon (SD) as I've experienced it already and for anyone else who's been there and got away with it, it can be quite an experience. Thankfully I wasn't in a high performance aircraft low to the ground like this crew who battled bravely all the way to save themselves and their aircraft. The report alludes to the fact that the crew were unfortunately unable to get into a stable wings level situation before a low-level abort was carried out and a rolling pull may have exacerbated the critical situation.

That's the real focus of the report for me and hopefully the AC.

Tadpole
26th January 2012, 21:23
PH,
I don't disagree with you at all. No crew ever takes off with the intention of getting involved in an accident and without fail they always try their damnedest to get out of any dangerous situation. Unfortunately some crews are unable to. While a report is a good yard stick of an accident it cannot tell me the thought processes or intentions of a crew. Therefore while I can measure what I see in the report I am in no position to question the crews reasoning. Would I, in the same position make the same choices?

However, as with every accident there is more then one reason. The Swiss cheese model. Arranged in a certain way you cannot see through it but line up the holes and the cheese becomes see through. Same with accidents, many layers, in all of which the holes must line up for the accident to occur.
While I understand that you may feel that people commenting negatively on the Air Corps as an organisation in light of this and other accidents have an axe to grind or vested interests, and maybe some have, the simple fact is that the Air Corps alone and nobody else have put themselves yet again in a position where their safety is questioned.

Yet what is truly astounding about the organisational aspects of this accident is that the Air Corps doesn't seem to have a 'corporate memory'. Where are the lessons learnt from the countless accidents and incidents in recent memory all to many of which have been fatal. Unfortunately its my impression that no matter what statistical yard stick you use; Crew fatalities as percentage of total; flight hrs per write off; write offs by fleet type; accidents training vs operations the Air Corps don't seem to have an enviable safety record.

hptmurphy
26th January 2012, 21:54
WTF..I was the second person to comment on the thread. All of a sudden there as a stack of posts on here posted prior to mine, but weren't visible at the time of my post, Had I seen any of these i would even want to be associated with the type of response its getting.

I was of the opinion that posting should be limited as opposed to a secondary investigation.

Shaqra
26th January 2012, 21:55
In any organisation there is a minimum capacity - be it headcount, missions executed, products produced - below which, if you fall under that level, the organisation becomes ineffective/dysfunctional. We've had many comments on related threads about work practices in the Don which undoubtably have a bearing on capability but you do have to ask whether the Air Corps has now fallen below critical mass. This is not a criticism of the organisation nor is it a plug for the ICG (which has the benefit of a major multinational corporate H/C operator to provide critical mass) - it is an observation based on 35 years seeing the A/C operate. The multi tasking of staff referred to above is not a choice - it's a function of trying to do too much with too few resources.

Helihead
26th January 2012, 22:05
The report alludes to the fact that the crew were unfortunately unable to get into a stable wings level situation before a low-level abort was carried out and a rolling pull may have exacerbated the critical situation.

That's the real focus of the report for me and hopefully the AC.

Sorry PH, but if that is the real focus for you and the AC as you put it, the bigger picture is being missed, and in my opinion we are going to be reading another accident report some where down the road. I really hope I will be proved wrong on that one.

hptmurphy
26th January 2012, 22:10
Unfortunately its my impression that no matter what statistical yard stick you use; Crew fatalities as percentage of total; flight hrs per write off; write offs by fleet type; accidents training vs operations the Air Corps don't seem to have an enviable safety record.

Show me a military air arm that has hasn't such a record, by the nature of the people involved , given that occassionaly envelopes are pushed beyond those normally associated with civil ops there may be a higher attrition rate,sometimes the stast highlight the facts that accidents can happen with a higher frequencey with people and machinery who are not not living working or operating within some of the more mundane profiles in life.

Both seemed quite competent, more than likely were and probably pushed the envelope at times.


An accident with attributable causes that would have been negated if they had't been military pilots just going that little bit beyond because of the training process they had been through which indeed does train them to push on regardless.

If military flying is like other aspects of the DF there is an andrenalin rush, fear and pressure often make you try things way outside the norm to make things work, if in the case of an aeroplane this is what people do to get situations to work when the chips may be down, thats a risk they take. I have no doubt that both knew there were acceptable risks in this situation, Up to 25 seconds before impact the trainee was fully participant, he had the option to opt out up to a couple of minutes before hand, the other side being up to that 25 seconds the captain had full faith in his trainee.

Attribute blame......Orville and Wilbur Wright and generations after them......give young men fast machines, tell them they are bullet proof they will want to try it.

neither man is at fault or the system wrong, the light that burns twice as bright only burns half as long.....Push it to far just once you may not get away with it.

Last multiple deaths was on a helo again a scratch crew trying to push the envelope , albeit with an unsuitable machine.

Risk taking, where the guys know what the potential is......

Tadpole
26th January 2012, 22:23
Jesus HPT,
Please never stand in my corner. While I know it's far from correct in the field of aviation you just made the AC look like uncontrolled cowboys.

Pure Hover
26th January 2012, 22:25
Sorry Tadpole, see your cheesy point alright but have to more or less disagree with you or your take on the accident. In this case there are no systemic causes identified and the only Contributary Factors are simply and clearly identified:

1. Continued flight towards high terrain in deteriorating weather
2. Very changeable weather conditions
3. High speed in a high terrain area where visibility was reduced

Unless I'm missing something they don't point to organisational issues! Yes it might have been better if the OC FTS was a PC9 pilot instead of an experienced Lear pilot but that IMO had no bearing whatsoever on the accident which was essentially a CFIT. Of course there are always points to be learned from any accident and the AC like any organisation will I hope seek to learn and move on. However the "countless accidents and incidents" you refer to "in recent memory" is misleading and a bit OTT don't you think!

Helihead
26th January 2012, 22:39
Show me a military air arm that has hasn't such a record, by the nature of the people involved , given that occassionaly envelopes are pushed beyond those normally associated with civil ops there may be a higher attrition rate,sometimes the stast highlight the facts that accidents can happen with a higher frequencey with people and machinery who are not not living working or operating within some of the more mundane profiles in life.

Both seemed quite competent, more than likely were and probably pushed the envelope at times.
An accident with attributable causes that would have been negated if they had't been military pilots just going that little bit beyond because of the training process they had been through which indeed does train them to push on regardless.

If military flying is like other aspects of the DF there is an andrenalin rush, fear and pressure often make you try things
way outside the norm to make things work, if in the case of an aeroplane this is what people do to get situations to work when the chips may be down, thats a risk they take. I have no doubt that both knew there were acceptable risks in this situation, Up to 25 seconds before impact the trainee was fully participant, he had the option to opt out up to a couple of minutes before hand, the other side being up to that 25 seconds the captain had full faith in his training.

Attribute blame......Orville and Wilbur Wright and generations after them......give young men fast machines, tell them they are bullet proof they will want to try it.

neither man is at fault or the system wrong, the light that burns twice as bright only burns half as long.....Push it to far
just once you may not get away with it.

Last multiple deaths was on a helo again a scratch crew trying to push the envelope , albeit with an unsuitable machine.

Risk taking, where the guys know what the potential is......


Sorry hptm, but with respect could I ask you to clarify. Your third post to this thread was asking BB what he meant in his previous post (#2) in relation to another thread which is currently active on this board. Are you saying that pushing the envelope and risk taking ( which is a mindset) is the military way. If that is the case would you agree it has no place where civilians are concerned.

sofa
27th January 2012, 00:11
Did the aircraft have the instrumentation to fly it out of trouble without needing to look out the window.?

Tadpole
27th January 2012, 00:48
PH,
Cheesy as you may see it I do believe it is valid. The organisational issues that I see in the report include the following (Bear in mind I see these as organisational, not individual failings)
1. Poor over sight.
2. Lack of direction to crews on speed in poor weather.
3. Failings in the FSS and auditing system; despite being recommendations of a previous reports.
4. Lack of external auditing.
5. No in flight training for Low Level Aborts (Despite the AC manual stating you will 'maintain proficiency')
6. A bizarre line in the manual that instead of instilling the use of the Low Level Abort as an emergency situation requires basically seeds in a pilots head that if you do a Low Level Abort you have f@@ked up. '; if it is your only option, you should have taken a better course of action earlier'


Of course there are always points to be learned from any accident and the AC like any organisation will I hope seek to learn and move on
On this we agree. I just hope they are implemented and adhered to fully unlike what appears to have happen previous report findings.


However the "countless accidents and incidents" you refer to "in recent memory" is misleading and a bit OTT don't you think!
On this one I dont really know where to start. I dont know what age you are so our 'recent memory' may be a little different but lets keep it to current and previous fleet only. (open to correction on these by any spotters out there!)

SF260WE Fleet 8: At least 3 written off, 2 fatal. At least a further 3 substantially damaged (Gormo field, Upside down 29, off the east of 23)
Cessna 172 Fleet 8: At least 4? written off, 1 fatal. At least another seriously damaged (Wires Knock)
Casa Fleet 2 plus 250: 250 barely escaped with the lives of 6(8?) people on board after flying IMC through a tree.
King Air Fleet 3: Actually none that I know about.
Gazelle Fleet 2: 1 written off.
AIII Fleet 8: 1 written off.
Dauphin Fleet 5: 1 written off, 1 fatal. 1 substantially damaged (Hanger Inver)
EC135 fleet 2: Again none that I know of.
AW139 Fleet 6: Two serious incidents with potential for loss. 1 IMC loss of control on delivery flight. 1 almost contact with underslung load (PC9 wing) 2 days? after the PC9 crash, load dumped before contact with aircraft. Interestingly after the previous removal of a Piper aircraft from the Wicklow mountains the IAC banned the lifting of aerodynamic surfaces. (lessons learnt?)
GIV Fleet 1: None
Learjet Fleet 1: None
PC9 Fleet 8: 1 written off, 1 fatal. At least 1(?) sent back to Pilatus after the airframe was overstressed.

Total fleet in recent years 54. AC written off 11. Fleet percentage written of 20.4%, not including the 9 substantially damaged aircraft or very close calls.

The above are only the ones that I know about. As I say, I am happy to be corrected on any of them but averaging about 6000hrs per year, the above even over the span of these fleets, just doesn't look particularly good. It is also interesting to note that very few of the above incidents happened under flight parameters that are not carried out by civil organisations on a daily basis therefore I for one don't accept the Military flying is dangerous mantra.

Charlie252
27th January 2012, 05:36
Like all accident reports it makes chilling and very sobering reading and for all those on the forum without an axe to grind or vested interest and who've actually taken the time to read the report in its entirity it forms the basis for comment and informed discussion on the inherent dangers and risks involved with aviation particularly in relation to SD and Somotogravic Illusion.
The research on the subject, well summarised in the report is extensive and grabs the attention. According to Newman (2007) in App D of the report "Spatial disorientation is a very common problem.....studies show that SD accounts for some 6 per cent to 32 per cent of major accidents and some 15 to 69 per cent of fatal accidents". He further asserts "It has been reported that for a given pilot, the career incidence of SD is in the order of 100 per cent....In other words, if a pilot flies long enough as a career or even a hobby there is almost no chance that he/she will escape experiencing at least one episode of SD. Looked at another way, pilots can be considered to be in one of two groups: those who have been disorientated, and those who will"

I'm certainly not in the category of those waiting to experience this phenomenon (SD) as I've experienced it already and for anyone else who's been there and got away with it, it can be quite an experience. Thankfully I wasn't in a high performance aircraft low to the ground like this crew who battled bravely all the way to save themselves and their aircraft. The report alludes to the fact that the crew were unfortunately unable to get into a stable wings level situation before a low-level abort was carried out and a rolling pull may have exacerbated the critical situation.

That's the real focus of the report for me and hopefully the AC.

CRM and accident investigation have developed over the last thirty years or so, we have for many years through the detailed work carried out by accident investigators been able to determine the exact actions by a crew that resulted in an accident, however the real advance has been in the examination of the processes and systems that resulted in that error.

I agree that the report is very well written and covers the physiological processes that can result in loss of SA. However I believe that is the result of a chain of events, let me give you an example.

A regional turboprop crash in the states, an inexperienced crew crashes an aircraft on a Dark and Snowy Night at a small regional airport. The accident report can explain in great detail the handling error made by the crew that resulted in the crash, they can identify which crew member manipulated which control which resulted in the crash, however this is only the first layer of investigation.
The more detailed modern view is to assess the chain of events that resulted in the crash.
In this case the Airline management spent as little money as possible on crew or crew training.
They paid very low salaries so only very inexperienced pilots were hired, they spent as little money as possible on training, so pilots received inadequate training and commanders were upgraded with minimal training and experience.
They would not invest in flight ops management so there was no oversight of crews and limited support to crews operating the flights.
And finally they based the inexperienced lowly paid pilots at far flung bases where they had to commute for duty on there own time, and then made them work long and difficult days in the poor weather of the northern US which led to chronic fatigue

The result was the pilots made an error which RESULTED in the crash, the fault lay with the Bean counters.
Of course the Bean Counters believe that Flight Safety is a given and would invest no money in that.

There is another accident closer to home that is scarily similar to the above.

I believe the same detailed examination should be applied to any Aviation accident and incident, I see that someone has detailed the AC accidents from the last 15-20 years, it fills me with no pride to see that listed nor do I feel any pride in the fact of knowing that it is the tip of the Iceberg. The near miss with the AW-139 within days of the PC-9 crash points to the AC’s stubborn self belief and naivety.

Flight Safety is not an Accident, I saw that on a poster many years ago, I think given my years of flying I finally understand the meaning of that poster

Charlie252
27th January 2012, 05:38
Show me a military air arm that has hasn't such a record, by the nature of the people involved , given that occassionaly envelopes are pushed beyond those normally associated with civil ops there may be a higher attrition rate,sometimes the stast highlight the facts that accidents can happen with a higher frequencey with people and machinery who are not not living working or operating within some of the more mundane profiles in life.

Both seemed quite competent, more than likely were and probably pushed the envelope at times.


An accident with attributable causes that would have been negated if they had't been military pilots just going that little bit beyond because of the training process they had been through which indeed does train them to push on regardless.

If military flying is like other aspects of the DF there is an andrenalin rush, fear and pressure often make you try things way outside the norm to make things work, if in the case of an aeroplane this is what people do to get situations to work when the chips may be down, thats a risk they take. I have no doubt that both knew there were acceptable risks in this situation, Up to 25 seconds before impact the trainee was fully participant, he had the option to opt out up to a couple of minutes before hand, the other side being up to that 25 seconds the captain had full faith in his trainee.

Attribute blame......Orville and Wilbur Wright and generations after them......give young men fast machines, tell them they are bullet proof they will want to try it.

neither man is at fault or the system wrong, the light that burns twice as bright only burns half as long.....Push it to far just once you may not get away with it.

Last multiple deaths was on a helo again a scratch crew trying to push the envelope , albeit with an unsuitable machine.

Risk taking, where the guys know what the potential is......

Seriously were you watching Topgun Again, "you can't think up there, if you think you die"

Helihead
27th January 2012, 13:26
I have to say, the last series of posts from TP AND 252, who seem to know what they are talking about have left me shocked. If it's the case that the series of incidents and accidents are fact, and I have no reason to think otherwise until someone counters with fact. In my opinion the IAC now have a duty of care to the public and to publish the reports mentioned that are still locked away somewhere gathering dust.

DirkinDaHerc
27th January 2012, 14:36
Hi all,

It was chilling reading this report, right down to the last transmission, and looking at the terrain.

My deepest sympathies to the family and friends, may no one else fall foul in future operations.

DITH

hptmurphy
27th January 2012, 19:17
Your third post to this thread was asking BB what he meant in his previous post (#2) in relation to another thread which is currently active on this board. Are you saying that pushing the envelope and risk taking ( which is a mindset) is the military way.

I'm posting in regard to this thread, no co relation should be taken from what is posted here. I could put down what I interpret from the report, I won't.I'm looking at it from a cultural overview as opposed to a specific incident.

The AAIU report has published its results,it is not for me to apportion blame, and I haven't.

While pushing the envelope and risk taking are often operational considerations to get the job done there are elements within the DF, all areas, who exceed the bounds of training in order to get the job done and reduce the safety margin at times.Again its a mindset often associated with younger people often given access to equipment, systems etc. that take very skilled operators to manage , exceed the bounds of safety and the outcome is often the result shown here.

Aviation is one of those fields where the results of some times exceeding the limits by the tiniest of fraction or overlooking something that may seem insignificant at the time, or even trying to test your self may turn fatal.


If that is the case would you agree it has no place where civilians are concerned.

I would whole heartedly agree this to be the case ,but the world of general aviation is not immune to characteristics often mis associated with military aviation,and the consequences are often the same, take your mind back to 1990 and an Accident in Cork involving two Cessna 152s where one hit the other,I knew the crews of both aircraft, this was an avoidable incident that happened in clear skies , there was blame attributable, these were guys trying to imitate what military fliers do.


Please never stand in my corner. While I know it's far from correct in the field of aviation you just made the AC look like uncontrolled cowboys.

This is not my intention, what should be taken from it that these are not sunday morning puddle jumpers piddling around at 100kts dropping in some where for a coffee along the way. This accident was due to a series of issues that escalated beyond reversal due to factors that had not either been given priority or due to the captain being of the belief that he was capable of dealing with them. 99 times in 100 they would have come out the right side of it,too many factors involved here and luck took a part.



Did the aircraft have the instrumentation to fly it out of trouble without needing to look out the window.?

Aircraft is IFR equipped,Training captain was qualified to do so but when the situation changes from VFR to IFR(IMC) so rapidly and the hand over of control only took place seconds before the crash there wasn't time enough to change the plan...the speed element and the height along with the terrain all become factors that have to be dealt with before you can establish an alternative.

Regarding the 'Top Gun' reference, doesn't come to mind.If you wish to suggest that my comments are based on how military pilots act on the big screen and that it influences how professional military pilots react, I refute that, but what I will say if you leave a man long enough in a room with a tea cosy, he will try it on.

It has to be remembered that if it was for the feats that often exceeded that expected of normal pilots, that general aviation pilots would not even consider, lives would have been lost as Aer Corps pilots showed bravery and professionalism of the highest order in carrying out life saving missions.Whether it be part of the mindset or aspects of training it certainly is that extra 10% that occassionaly makes the difference,

Charlie252
27th January 2012, 19:43
I don't believe that risk taking and pushing the envelope have any place in aviation, this old nugget permeated the AC for many years where there was a belief that Military Pilots didn't need limits!!. I think that this is clearly not true, all aviation professionals should operate within the limits of the aircraft and their abilities. Pushing the limits leads to incidents and accidents.

The AC have a fine record of life saving in the SAR arena for sure, however we now know that SAR can be performed equally as effectively by a regulated(AOC) organization. (I don't wish to drag the efficiency merits into this discussion.) In my opinion the Training in the AC is excellent an many areas, I think the organization falls down in the application of this training and in its management structure and flight ops regulation and supervision, remember that the IAC is the regulator and operator...

A frontline fighter squadron operating in a hostile environment may have to push the limits to get ordnance on target or to escape from AA fire, but even my knowledge and contact with pilots flying Supersonic fighter aircraft leads me to believe they operate to a very strict set of SOP's and are actually highly regulated.

None of which really maters in the context of the AC, where all of the operations could be covered by an AOC.

I don't believe that AC mission effectiveness would have been reduced by the application of Professional Limits and Robust SOP's backed up by effective flight ops management and performance monitoring.

GoneToTheCanner
27th January 2012, 20:05
Hi there
With regard to changes required to the AC system, D248 produced more institutional changes than even this accident. I served there before 248 and quite simply, the place was accidentally professional. The Don got a severe boot up the hole from 248's outcome and no doubt will get the same from 265. I have always wanted Don accident reports to be published because I belive that the public, who pay for their very existence, have a right to know and also because other air arms do so as a matter of routine.

regards
GttC

Helihead
27th January 2012, 20:17
I would whole heartedly agree this to be the case

hpt, thanks for the clarification.

DeV
27th January 2012, 21:00
I don't believe that risk taking and pushing the envelope have any place in aviation
Everytime you step in board an aircraft (same as a car) you are taking a calculated risk.


A frontline fighter squadron operating in a hostile environment may have to push the limits to get ordnance on target or to escape from AA fire, but even my knowledge and contact with pilots flying Supersonic fighter aircraft leads me to believe they operate to a very strict set of SOP's and are actually highly regulated.

I don't believe that AC mission effectiveness would have been reduced by the application of Professional Limits and Robust SOP's backed up by effective flight ops management and performance monitoring.

What makes you think there weren't SOPs?

DeV
27th January 2012, 21:17
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.

Helihead
27th January 2012, 21:50
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.

???

hptmurphy
27th January 2012, 22:26
Everytime you step in board an aircraft (same as a car) you are taking a calculated risk.

Agreed


I don't believe that risk taking and pushing the envelope have any place in aviation

Again agreed.


The AC have a fine record of life saving in the SAR arena for sure, however we now know that SAR can be performed equally as effectively by a regulated(AOC) organization. (I don't wish to drag the efficiency merits into this discussion.)

Given the aircraft involved I believe that there were times where boundaries were exceeded but not to the point of recklessness,but sometimes pushing the limits in training give you an insight to what maybe available when required operationally .

If all were to operate within a comfort zone we would have no heroes!
The guys on the night of July 1st 1999 in 248 were well outside their comfort zone from the missions inception, but something else kicked in to make the push that extra 10%.

Someone some where at some point in their training had instilled that value in them that should they believe it was justifiable to move out side of the accepted safety zone to get the job done and if the risks were acceptable they were justified in their actions.

It has been proven to have tragic results at times but if every situation were to be put under the micro scope with the precision of an AAIU investigation , how may would be found to be flawed at the time of the action.

Given some of the finest pilots crew people and even the AAIU people have come through the Air Corps system I'm slow to find fault with the people.

The management checks and balances may need adressing but we only find out these things after incidents such as this.

If a report such as this finds systems failures it is the management that are negligent and not the individual, as was the proven case from the Tramore Incident.

Incidents as opposed to accidents, Incidents happen because of failures, accidents because of a quirk of fate, each person has to decide for themselves if there were failures and where the failures lay, if they were reported and who was responsible.

If we say all fighter pilots were reckless and guilty of 'Hot Dogging' as the Americans call it, how come the Fougas were free of such incidents?

Marchettis had the same potential and yes there were losses.

We should have had more accidents with Dauphins, we got away with it.

I'm afraid on the day, there is a luck element to be factored in.

DeV
27th January 2012, 22:49
???

Read the report!

Goldie fish
27th January 2012, 23:36
PH,
Cheesy as you may see it I do believe it is valid. The organisational issues that I see in the report include the following (Bear in mind I see these as organisational, not individual failings)
1. Poor over sight.
2. Lack of direction to crews on speed in poor weather.
3. Failings in the FSS and auditing system; despite being recommendations of a previous reports.
4. Lack of external auditing.
5. No in flight training for Low Level Aborts (Despite the AC manual stating you will 'maintain proficiency')
6. A bizarre line in the manual that instead of instilling the use of the Low Level Abort as an emergency situation requires basically seeds in a pilots head that if you do a Low Level Abort you have f@@ked up. '; if it is your only option, you should have taken a better course of action earlier'


On this we agree. I just hope they are implemented and adhered to fully unlike what appears to have happen previous report findings.


On this one I dont really know where to start. I dont know what age you are so our 'recent memory' may be a little different but lets keep it to current and previous fleet only. (open to correction on these by any spotters out there!)

SF260WE Fleet 8: At least 3 written off, 2 fatal. At least a further 3 substantially damaged (Gormo field, Upside down 29, off the east of 23)
Cessna 172 Fleet 8: At least 4? written off, 1 fatal. At least another seriously damaged (Wires Knock)
Casa Fleet 2 plus 250: 250 barely escaped with the lives of 6(8?) people on board after flying IMC through a tree.
King Air Fleet 3: Actually none that I know about.
Gazelle Fleet 2: 1 written off.
AIII Fleet 8: 1 written off.
Dauphin Fleet 5: 1 written off, 1 fatal. 1 substantially damaged (Hanger Inver)
EC135 fleet 2: Again none that I know of.
AW139 Fleet 6: Two serious incidents with potential for loss. 1 IMC loss of control on delivery flight. 1 almost contact with underslung load (PC9 wing) 2 days? after the PC9 crash, load dumped before contact with aircraft. Interestingly after the previous removal of a Piper aircraft from the Wicklow mountains the IAC banned the lifting of aerodynamic surfaces. (lessons learnt?)
GIV Fleet 1: None
Learjet Fleet 1: None
PC9 Fleet 8: 1 written off, 1 fatal. At least 1(?) sent back to Pilatus after the airframe was overstressed.

Total fleet in recent years 54. AC written off 11. Fleet percentage written of 20.4%, not including the 9 substantially damaged aircraft or very close calls.

The above are only the ones that I know about. As I say, I am happy to be corrected on any of them but averaging about 6000hrs per year, the above even over the span of these fleets, just doesn't look particularly good. It is also interesting to note that very few of the above incidents happened under flight parameters that are not carried out by civil organisations on a daily basis therefore I for one don't accept the Military flying is dangerous mantra.

You can add to that list the Fouga that landed in a field in Cork, and the GASU heli(flown by air Corps) that sufferred a sudden loss of altitude due to pilot disorientation. The latter is noteworthy as some of the contributing factors also emerged in this latest tragedy.

Charlie252
28th January 2012, 04:55
"What makes you think there weren't SOPs?"

Hi Dev, please reread my post, "Professional Limits and Robust SOP's backed up by effective flight ops management and performance monitoring." I don't think writing a set of SOP's automatically produces flight safety, the other parts of my post are the other essential pieces if the Pie.

During my career we operated in a Vacuum with regard to SOP's and even where there were SOP's, they were more "Advisory" in nature, best example is Flight Duty Limits... but there were many others

Charlie252
28th January 2012, 05:13
Agreed



Again agreed.



Given the aircraft involved I believe that there were times where boundaries were exceeded but not to the point of recklessness,but sometimes pushing the limits in training give you an insight to what maybe available when required operationally .

If all were to operate within a comfort zone we would have no heroes!
The guys on the night of July 1st 1999 in 248 were well outside their comfort zone from the missions inception, but something else kicked in to make the push that extra 10%.

Someone some where at some point in their training had instilled that value in them that should they believe it was justifiable to move out side of the accepted safety zone to get the job done and if the risks were acceptable they were justified in their actions.

It has been proven to have tragic results at times but if every situation were to be put under the micro scope with the precision of an AAIU investigation , how may would be found to be flawed at the time of the action.

Given some of the finest pilots crew people and even the AAIU people have come through the Air Corps system I'm slow to find fault with the people.

The management checks and balances may need adressing but we only find out these things after incidents such as this.

If a report such as this finds systems failures it is the management that are negligent and not the individual, as was the proven case from the Tramore Incident.

Incidents as opposed to accidents, Incidents happen because of failures, accidents because of a quirk of fate, each person has to decide for themselves if there were failures and where the failures lay, if they were reported and who was responsible.

If we say all fighter pilots were reckless and guilty of 'Hot Dogging' as the Americans call it, how come the Fougas were free of such incidents?

Marchettis had the same potential and yes there were losses.

We should have had more accidents with Dauphins, we got away with it.

I'm afraid on the day, there is a luck element to be factored in.

Hi,

Again you persist in the belief that somehow military pilots are supermen and limits are a target. In my opinion there is no extra 10%, there are limits.. its either safe or not..
Certainly there was a perception in the AC for many years that we as Military Pilots did not require Limits, this was stated by Senior Officers, and there was always a reluctance to write anything in ACFO's that would limit the AC's much vaunted Operational Flexibility.
I think quite clearly given the High level of accidents and incidents over the years that something was wrong with that approach.

The Fougas appear to have had a very safe and long career, and certainly we never had a fatality. But the aircraft retired with a fleet airframe average hours of about 2000hr, and believe me there were plenty of close calls...

Helihead
28th January 2012, 08:44
Read the report!

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

Tadpole
28th January 2012, 09:19
If you want to be picky about it no management issues were found to be direct causes to this accident, however the report mentions a number of management issues that were at least 'failings' and for me the kicker is this:

The final fatal dive appears to have been caused by severe disorientation caused by the low level maneuvering followed by an attempted low level abort, which at least initially cleared the immediate terrain.
The IAC PC9 manual gives clear direction that a low level abort can cause severe disorientation, it also states that the pilot will 'maintain proficiency'. Yet up until the time of the accident the IAC pilots did not practice in flight low level aborts. So, the final fatal act of the accident was caused by a well known side effect of the low level abort, one which is outlined in the IAC manual and 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?

Goldie fish
28th January 2012, 10:11
I think it is ironically unfortunate that the disorientation that caused the loss was a topic that the Instructor was considered an expert on.

Tadpole
28th January 2012, 10:22
Hi Golide,
Unfortunately in many walks of life having the knowledge and practical application are 2 completely different things. While awareness and knowledge arms the pilot for such dangers absolutely nothing trumps hands on experience.

hptmurphy
28th January 2012, 17:33
Again you persist in the belief that somehow military pilots are supermen and limits are a target. In my opinion there is no extra 10%, there are limits.. its either safe or not..

ok



Certainly there was a perception in the AC for many years that we as Military Pilots did not require Limits, this was stated by Senior Officers, and there was always a reluctance to write anything in ACFO's that would limit the AC's much vaunted Operational Flexibility.

Is there a possibility that elements of that culture still exist?



I think quite clearly given the High level of accidents and incidents over the years that something was wrong with that approach.

We only become aware of such incidents when they end up with fatal circumstances, however if all incidents were to be tabulated would it show that there is a lack of management?

It was cited in the report that the PIC charge had been investigated for a low flying incident. If all these were to be presented does it increase the amount of 'incidents' dramatically?


Would currency and proficiency in low level aborts have saved this crew?
Why was the required proficiency not carried out?

Has the matter been raised at those levels that manage such issues?


Still think management have nothing to answer for?

If the questions are raised then they have to account for lack of input.

Problem being who gets to ask the questions?


The Fougas appear to have had a very safe and long career, and certainly we never had a fatality. But the aircraft retired with a fleet airframe average hours of about 2000hr, and believe me there were plenty of close calls.

I have no doubt but the incidents are not in the public arena so I can't comment.


I'm taking from all this that the lack of external auditing of the systems in place has failed to highlight

(a) That procedures are not being adhered to
(b) that those tasked from within the Aer Corps with self assessment of the systems are either overlooking basic system failures or are not aware of the potential risks around what they area auditing because they not be qualified to the degree required to carried out impartial audits.

So in effect the AC has not moved on from the Tramore incident and the flaws pointed out in the management structure back then have either never been adressed or have been allowed to resurface if they had indeed been removed?

So in effect while the people continue to fly they do so in an environment that lacks the control to minimize accidents?

Am I reading that correctly?

sofa
28th January 2012, 18:09
You can have all the best training, procedures, tools etc. in place, but if a pilot makes a decision. or a trainee in a marchetti on a solo flight decides to try

a loop de loop not much management can do about that.

loki
28th January 2012, 18:24
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. I joined IMO recently having been a spectator for quite a while, maybe I joined at a bad time but the experience has left a bad taste in the mouth. And for that reason, as Duncan Banatyne might say, I'm out. Cheerio IMO.

Charlie252
28th January 2012, 19:24
ok




Is there a possibility that elements of that culture still exist?




We only become aware of such incidents when they end up with fatal circumstances, however if all incidents were to be tabulated would it show that there is a lack of management?

It was cited in the report that the PIC charge had been investigated for a low flying incident. If all these were to be presented does it increase the amount of 'incidents' dramatically?



Has the matter been raised at those levels that manage such issues?


Still think management have nothing to answer for?

If the questions are raised then they have to account for lack of input.

Problem being who gets to ask the questions?



I have no doubt but the incidents are not in the public arena so I can't comment.


I'm taking from all this that the lack of external auditing of the systems in place has failed to highlight

(a) That procedures are not being adhered to
(b) that those tasked from within the Aer Corps with self assessment of the systems are either overlooking basic system failures or are not aware of the potential risks around what they area auditing because they not be qualified to the degree required to carried out impartial audits.

So in effect the AC has not moved on from the Tramore incident and the flaws pointed out in the management structure back then have either never been adressed or have been allowed to resurface if they had indeed been removed?

So in effect while the people continue to fly they do so in an environment that lacks the control to minimize accidents?

Am I reading that correctly?


IMHO Yes.

Charlie252
28th January 2012, 19:27
You can have all the best training, procedures, tools etc. in place, but if a pilot makes a decision. or a trainee in a marchetti on a solo flight decides to try

a loop de loop not much management can do about that.

I agree completely, if the stuff you mentioned is not there, the chances are greatly increased..

GoneToTheCanner
28th January 2012, 20:03
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
28th January 2012, 21:16
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
28th January 2012, 22:21
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
29th January 2012, 14:00
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
29th January 2012, 14:49
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
29th January 2012, 15:02
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
29th January 2012, 15:14
I say again according to the completely independent AAIU report - The flight crew were appropriately qualified with valid IAC ratings.

Tadpole
29th January 2012, 15:23
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
29th January 2012, 15:38
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
29th January 2012, 15:46
The AAIU didn't find that to be a contributing factor in the accident!

hptmurphy
29th January 2012, 15:50
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
29th January 2012, 16:03
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
29th January 2012, 16:11
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
29th January 2012, 16:12
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
29th January 2012, 16:18
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
29th January 2012, 19:13
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
29th January 2012, 23:04
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
4th March 2013, 15:11
http://www.rte.ie/news/2013/0304/372157-connemara-crash-inquiry/

Interesting turn of events.

Meatbomb
4th March 2013, 19:08
Would the findings of the inquiry be made public?

GoneToTheCanner
5th March 2013, 13:53
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
5th March 2013, 14:21
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
5th March 2013, 15:15
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
5th March 2013, 16:03
Giving that the Court of Inquiry is a closed court we don't know what they are!

Tadpole
5th March 2013, 16:40
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
5th March 2013, 21:04
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.

DeV
5th March 2013, 22:31
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

Helihead
6th March 2013, 08:25
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.

Tadpole
6th March 2013, 09:36
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.

Jetjock
6th March 2013, 11:32
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.

DeV
6th March 2013, 11:36
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!

Tadpole
6th March 2013, 12:47
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?

Jetjock
6th March 2013, 13:21
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.

DeV
6th March 2013, 14:05
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

Cesssenacavanman
6th March 2013, 15:24
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?

DeV
6th March 2013, 17:59
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

hptmurphy
6th March 2013, 19:34
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.

sofa
6th March 2013, 23:52
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.

Meatbomb
7th March 2013, 00:11
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.

Jetjock
7th March 2013, 00:17
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.)

Tadpole
7th March 2013, 00:24
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.

Tadpole
7th March 2013, 00:31
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.

Jetjock
7th March 2013, 01:02
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.

sofa
7th March 2013, 01:05
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.

Tadpole
7th March 2013, 01:19
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

DeV
7th March 2013, 01:52
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.

Charlie252
7th March 2013, 02:32
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!!

Cesssenacavanman
7th March 2013, 13:43
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.

Goldie fish
7th March 2013, 15:00
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.

GoneToTheCanner
7th March 2013, 20:32
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

hptmurphy
7th March 2013, 22:41
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.

danno
7th March 2013, 22:48
........ 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.

Meatbomb
7th March 2013, 23:56
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.

DeV
8th March 2013, 00:25
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.

http://www.aaiu.ie/about-us

Helihead
8th March 2013, 08:27
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.

http://www.irishtimes.com/newspaper/ireland/2013/0308/1224330912891.html

GoneToTheCanner
8th March 2013, 10:36
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

hptmurphy
8th March 2013, 19:46
Regarding the AAIU being neutral ,I think when incidents involving AC are involved , having a former AC officer on the lead of an investigation is somewhat open to suggestion.

I'm not for one minute suggesting that Jurgen Whyte is not impartial, but I wouldn't want Jimmy Saville as my kids doctor!

One of the big critiscism here is that with military aviation people almost expect accidents, look at the pages of Air Forces monthly and the world is full of them, You tube same thing , 90% of the population other than those directly affected are immune to them, but lets put them in perspective.

Because loss of life is usually limited to those on board, its treated no waorse than a road accident, lets say for example if an Aer Lingus aircraft is lost and all 350 people on board are killed and the AAIU dig into operations procedure and come up with the type of management failures that have been endemic of military aviation in this country in the past number of years, heads would role.

Back to my point, its seems to be almost acceptable to have losses in military aviation,because of the perception of military aviators as portrayed in the media.

The public doesn't understand the potential consequences of a PC 9 hitting a school...

If there is an eventuality that may occur , then there should be a check put in place to know that all pilots operating the aircraft can deal with it. It is unacceptable to find that 'X' has never been taught as it never happened before.
Gttc highlights it from an engineering side based on personal experience, he also offers an opinion on management structures, I tend to agree.

There are still organisations within the entire DF that are run on a nod and a wink basis. While it may go un noticed in most day today operations ,aircraft are fa less forgiving and can't be operated on a nod and wink basis.

There are some who are blameless and do their job to the best of their ability , but if a structure allows people to progress with all the training they need to operate in their roles without the potential for the type of incident that are becoming far to frequent something is inherintly awry.

Given 75% of the role involving PC 9s specifically is training, how hard can it be to get it right.,

Laziness amounting to criminal negligence comes to mind. It would appear even after the 248 crash despite the 'shake up' nothing has changed, and it has cost at least three more lives to date.

Jetjock
8th March 2013, 20:29
Hi murph,

If you read the report again you will find that Mr Whyte is indeed critical of the structures and asks all the questions that needed to be asked. The problem the Jevins family are having is the internal Air Corps "inquiry".

I would be loath to let even an implied suggestion of impartiality to stand without reply. I have huge respect for the AAIU and the job they do. It's often not an easy one.

Rather then viewing Mr Whyte as being selected to lead this investigation despite his Air Corps background, I would venture he was selected because of it.

hptmurphy
8th March 2013, 22:50
The Man on street when looking at an Inquiry involving a former AC officer would have a tainted point of view that the port may not be all that it could.

Its easy be critical of the structures , why not recommend that the force be discontinued from flying until the results of the investigation are evaluated and possibly elevated to recommendation status and even enforce,the recommendations

An external audit needs to be applied by a third party with no affiliation to the air corps and have its findings publish and more importantly acted on.

the AAIU are not up to the job the have despite there being fatal incidents all around similar circumstances have fail to ground the air corps until an acceptable standard of safety and consistencey in basic training and management have been acheived.

The families of 248 were given guarantees that reviews would take place and related incidents due to oversights would not reoccur.

It hasn't changed.


I would venture he was selected because of it. If he is to assume the role of Whistle blower, why only after another accident, there should have been regular reviews of AC procedures when the AAIU found there to be deficiences going back to 1999,

the AC needs to be brought under external auditory control until it is proven they can provide their own flight training and management of training operations and what ever else falls out of the closet without incurring losses because of non adherance to principles to deal with the type of incident that has currently cost at least seven men their lives.


the recent incident where a Pilot on Air Ambulance duty who wrecked his machine again is something yet to be published, what can of worms will it unearth?

Cesssenacavanman
8th March 2013, 23:24
http://www.irishtimes.com/newspaper/ireland/2013/0308/1224330912891.html

Jesus...


the then serving General Officer Commanding (GOC) Air Corps and two officers responsible at the time for flight safety and the flight training school were not interviewed.


the report’s failure to identify the absence of flight safety audits in the Air Corps training school between 2004 and 2009 as an issue.

Jetjock
8th March 2013, 23:30
Murph this is obviously a subject that evokes anger in you but I think you might misunderstand the role of the AAIU. They have no powers of grounding.

The AAIU are completely, totally and utterly separate from the IAA, the regulator. Even the IAA's grounding powers do not extend to the military.

The only individual with the power to issue a total grounding order for the AC would be the Minister. A failure in the internal oversight of the Air Corps is by default a Departmental failure in the oversight of the military.

The AAIU report into this crash was one of the most comprehensive they have ever produced. It went much deeper than the crash itself. It pulled not one single punch.

It is a factual document that those people on here who have long talked about the internal failings in the IAC can point to and say "I told you so".

It's obviously an emotive issue for you but we need to get a grip on expecting the AAIU to step outside its mission statement. It has advanced this as far as it can, the onus is on other organisations to act accordingly.ie this needs to be advanced by the Dept.

Any suggestion of impartiality is completely disproven by the content of the report. You do not need to read between the lines to see the damning evidence it lists.

DeV
9th March 2013, 01:20
Intercontinental Aviation Safety Consultants did an audit in 2001.
http://oireachtasdebates.oireachtas.ie/debates%20authoring/debateswebpack.nsf/takes/dail2001032800022?opendocument
http://www.aaiu.ie/sites/default/files/upload/general/13093-SR12_2000-0.PDF


Not sure if there have been any since

Tadpole
9th March 2013, 02:14
Yeh, an American company with an American outlook on safety. You know, the ones with the worlds worst EMS safety record and consider SE aircraft suitable of operations over hostile environments. Talk about a square peg for a round hole!!

Charlie252
9th March 2013, 02:35
I don't believe there is any value in discussing the independence or otherwise of the AAIU (I believe they are), the reports into the recent crashes have been comprehensive and have been critical, in as far as they can be, of the organization.

The issue is that, unlike in the commercial/regulated world, the reaction of the organization and its drive to change can only come from within and without anyone being held accountable the change will be fairly minor and short lived.

A single safety audit completed in 2001 does not really scratch the surface!!

GoneToTheCanner
9th March 2013, 15:03
As with all AAIU reports, it's the unwritten stuff that contains the nuggets. Not interviewing the GoC is a major error. If a civilian trainer crashed, the owner of the school would be interviewed as a matter of course. Unfortunately, the man who "sent" the two men on their way was the man who died, so he can't be quizzed about his actions. In effect, we are left with the aircraft's electronic record and a radar track and a comms record to sort out fact from fiction. With regard to the Don's corporate mentality, for want of another word, it has always touted it's pilots as being the best and it has never liked them to be found wanting. The thing is, the Don has improved vastly in many ways since 248 but I suspect that there will always be gaps in the training and certain mentalities, that are in effect, not tolerated in civvie street. This doesn't mean that civvie operators are saints, either, but at least they seem to react quicker and are under tighter scrutiny.

regards
GttC

Cesssenacavanman
9th March 2013, 16:10
The article i quoted regarding GOC not being interviewed along with the officers responsible for FTS and flight safety was referring to the military inquiry, not the AAIU report.

So no safety audits between 2004 and 2009 even though there should have been, and the officer in charge of flight safety at the time wasn't interviewed. What the actual f***?

DeV
9th March 2013, 17:47
I agree but remain we are reading this in a paper that claims to have seen what is probably a restricted document.

If a Ryanair flight had a fatal accident would Michael O'Leary be interviewed by the AAIU ?

Charlie252
9th March 2013, 20:14
I agree but remain we are reading this in a paper that claims to have seen what is probably a restricted document.

If a Ryanair flight had a fatal accident would Michael O'Leary be interviewed by the AAIU ?

Most likely MO'L would not be interviewed but the Director of Flight Operations, the Head of Training and the Director of flight safety would be grilled!

The "Post holders" or "accountable managers" would feel the heat for sure.

danno
9th March 2013, 21:19
Equally the Minister,who has overall corporate responsiblity,would not be interviewed unlees he/she had directly got involved in the op concerned.
Perhaps a better rule of thumb regarding who should be interviewed would be to grill those that invariably wheel themselves out for the limeoight whenever the org concerned is under a positive spotlamp.
The real diff between the civvy ops and others is not so much self/external regulation but the fact that the civvy op will fold if it suffers from adverse oversight with loss of jobs to all concerned.

hptmurphy
9th March 2013, 21:30
While the IAA and the AAIU are separate bodies the IAA have the remit to act on information uncovered by the AAIU.

While they may not be able to interfere in military based operations they have the authority to pass information onto the relevant departments and have them authorize a grounding.

Internal military enquiries are not worth a shit, especially when they may have to apportion blame .

Ultimately the minister is liable and no doubt the whole thing will end in the department and not at someones door in the AC.

DeV
10th March 2013, 00:47
The IAA is the auditing body for the ICAO in Ireland but "State" aircraft are exempt.

Tadpole
10th March 2013, 09:52
The IAA is the auditing body for the ICAO in Ireland but "State" aircraft are exempt.

And there in lies the very problem.
However, JAR / EASA also state that State aircraft should be operated as closely to JARs / EASA regulations as possible and it is the State's obligation to ensure this is done. Now as a State body why cant the State decide to dedicate a unit of the IAA to oversight and control of military standards and operations. After all since the boom ended the IAA have spare capacity.

GoneToTheCanner
10th March 2013, 14:53
...and what would happen is that it would be filled with exers who would not do a tap, especially against their old school. Another point too is that the entire DF was exempt from a lot of the normal industrial 'elf 'n' safety protocols that were the norm in the civvie world. The DF could, and did, exclude H & S people if they wanted to. Certainly, in the Don, the hangars and workshops, in the 80s and 90s, were dreadfully below par and didn't beging to enter modern standards until the building of the new hangar and the flattening of old workshops. So, if the stuff on the groudn was in rag order, what hope was there for anything else?

regards
GttC

hptmurphy
10th March 2013, 15:10
What if the AAIU s report and the Air Corps investigation don't match?

Who is lying ?

Tadpole
10th March 2013, 17:16
...and what would happen is that it would be filled with exers who would not do a tap, especially against their old school.
And in the event of an accident where the inspector didn't enforce standards he also becomes personally responsible. If there's one thing that cuts the 'old school' s**t, its having your ass on the line.

GoneToTheCanner
10th March 2013, 19:17
Well, an AAIU man is less inclined to sweat over his career than someone involved in the background to an accident and as they will freely tell you, people lie to them the whole time. Also, inadequacies in a system, such as the Don, are not always easy to spot if you have never been exposed to any other environment. The DF are like everyone else, they don't like having their dirty laundry aired in public. They certainly don't like their inadequacies being shown back to them, especially when they trumpet their achievements the whole time.

regards
GttC

Goldie fish
15th March 2013, 14:38
From the Dail Yesterday:

Air Accident Investigations

5. Deputy Joe Higgins asked the Minister for Defence if he will order the reopening of the military enquiry covering the crash of an Air Corps Pilatus PC-9 aircraft in County Galway on 12 October 2009 resulting in two fatalities and the concerns raised by the parents of one of the Air Corps personnel killed (details supplied) regarding the conduct of the investigation. [13525/13]

Deputy Fergus O'Dowd: I wish first to extend my sympathies to the families of the deceased. There have been three separate reports into this tragic accident. The air accident investigation unit of the Department of Transport conducted an inquiry and published its report on 24 January 2012. It found that the probable cause of the accident was spatial disorientation of the instructor-pilot in conditions of poor visibility, resulting in a controlled flight into terrain. The subsequent inquest into the deaths of the two crew members recorded an open verdict in respect of the instructor-pilot who was piloting the aircraft at the moment of impact and a verdict of accidental death for the cadet.

The court of inquiry’s findings are in complete agreement with those reached in the earlier investigations, namely, that the accident was caused by spatial disorientation of the instructor, who was piloting the aircraft in conditions of poor visibility. All of the reports agree that the cadet bore no responsibility of any kind for the accident. The Minister, Deputy Shatter, is willing to address any questions about the court of inquiry and has asked the Attorney General for advice in this regard. However, he is satisfied that the court of inquiry has done its work in a thorough way and that its members acted professionally, impartially and with integrity.

Deputy Joe Higgins: On 12 October 2009, as the result of a crash on an Air Corps training flight, Cadet David Jevens tragically died, as did Captain Derek Furniss. In the question I tabled I asked that the court of inquiry's investigation be reopened. The Minister of State indicated that the Attorney General has been asked to provide advice, and I welcome that in so far as it goes. However, much more needs to be done.
The father of the late Cadet Jevens's is observing in the Visitors' Gallery. The family of the late Cadet Jevens, in particular, are deeply unhappy with the conduct of the court of inquiry for a number of specific reasons. The first of these is that Defence Force regulation A5(2) directs that a certified copy of the proceedings in the Coroner's Court be forwarded to the court of inquiry. This was not done. Evidence was given at the Coroner's Court and the cross-examination of witnesses in that court yielded vital evidence about the tragedy. Important parts of that evidence were contracted during the proceedings of the court of inquiry, but no attempt was made to reconcile the differences that came to light or to cross-examine witnesses. The second reason is that no safety audit was carried out in the flight training school between 2004 and early 2009. There was criticism of this fact in the air accident investigation unit's report. However, the then flight safety officer was never called before the court of inquiry. The third reason is that the commanding officer of the flight training school was on other duties for more than half of the time leading up to and during 2009. He was never called upon to give evidence before the court of inquiry.

An Leas-Cheann Comhairle: Will the Deputy please ask a question?

Deputy Joe Higgins: The final reason is the fact that witnesses were given copies of the questions to be asked a long time before the court of inquiry sat. They presented written statements, in respect of which they were not cross-examined, and which in some cases differed substantially from the evidence of the air accident investigation unit and of the coroner. No attempt was made to reconcile this. I put it to the Minister of State that there is a compelling argument to reopen the court of inquiry and I ask that this be done.

Deputy Fergus O'Dowd: I again offer my deepest sympathies to the families of Cadet Jevens and Captain Furniss in respect of this awful tragedy. I reiterate that the Minister for Defence, Deputy Shatter, has arranged for all of the relevant issues that were raised to be forwarded to the Attorney General for advice. The Minister is available to meet the families of the deceased at any time.

In the context of the findings of the air accident investigation unit, all of the seven safety recommendations have been implemented and acted upon. However, due the nature of some of those recommendations, work remains ongoing in two specific areas: the recommendation concerning external input into the Air Corps safety management system, SMS, and that concerning the implementation of flight data monitoring. The position in respect of the former is that the Air Corps has accepted a suggestion with regard to the inclusion of external inputs in the SMS auditing process and is sourcing a suitable expert in this regard. The position on flight data monitoring is that a study has been completed and steps have been taken to commence the implementation of recommendations to equip all aircraft in the fleet with flight data monitors

Deputy Joe Higgins: I take it the Attorney General would be prepared to accept a submission from the family of Cadet Jevens. I shall so advise them; that would be normal. I have to ask that, in the reopening of this court of inquiry, the family of Cadet Jevens be represented, and the family of Captain Furniss should they wish. It is vital that the families would have the opportunity of being represented to represent the name and vindicate the rights of their loved ones who tragically died.
Deputy Fergus O'Dowd: I accept the points Deputy Higgins has made and I will ensure they are brought to the attention of the Minister, Deputy Shatter. All of the issues raised up to now, and I am not familiar with all of them, have been addressed in the context of being sent for legal advice but if there are any other submissions the Deputy or the families wish to make, I have no doubt that on receipt of them the Minister, Deputy Shatter, will pass them on.

Tadpole
15th March 2013, 21:58
Sorry, did I read that correctly? The Defence Forces held a Court of Inquiry into a fatal aircraft accident and never interviewed the unit OC or the Flight Safety Officer. Comprehensive enquiry there so......

GoneToTheCanner
16th March 2013, 13:03
Well, in effect, the day-to-day OC was dead and the FSO covers the whole Air Corps, not just the PC-9s, so the number of people who had direct input into the PC-9 flight is very small. If existing practise was anything to go by, they(the AC) would have seized the aircraft logbooks immediately and got hold of the NCO ic and the men who dispatched it and quizzed them first.

regards
GttC

DeV
16th March 2013, 15:26
The day-to-day OC (CFI) yes but not the OC FTS.

danno
16th March 2013, 19:33
Well, in effect, the day-to-day OC was dead and the FSO covers the whole Air Corps, not just the PC-9s, so the number of people who had direct input into the PC-9 flight is very small. If existing practise was anything to go by, they(the AC) would have seized the aircraft logbooks immediately and got hold of the NCO ic and the men who dispatched it and quizzed them first.

regards
GttC

Thats all fine and well iff the aircraft condition is a material factor in whatever befell it.

Cesssenacavanman
16th March 2013, 19:49
But surely the FSO should have questions to answer regarding no safety audits taking place between 2004 and 2009?

Cesssenacavanman
16th March 2013, 22:55
Thinking about it again, wouldn't the OC be responsible for what training his instructors should be doing. For example should the then OC have been questioned on why low level abort training was not done?

That added to my last point makes it very worrying and in my mind very suspicious that the then OC and then FSO were not questioned by this inquiry. Unwillingness to ask hard questions and discipline anyone?

GoneToTheCanner
17th March 2013, 17:31
hi all,
Seizing the maintenance logs is standard so that no-one can enter anything after the fact. So is quizzing the techs. All persons connected directly or indirectly with a flight are questioned, so omitting persons in the command chain, especiallyon such a short one as the PC-9 chain is wrong.

regards
GttC

Meatbomb
17th March 2013, 18:44
It's my honest opinion that if the AC really wanted to know ALL the factors that led to the accident they would have left no stone unturned so that it could never happen again. To do anything less is disrespectful to those that died and their families.
This inquiry was not comprehensive enough and was just a tick the box exercise to be seen to do something.

DeV
17th March 2013, 18:52
I wouldn't rely on the papers to be 100% accurate.

Who is to say that written statements weren't given

Meatbomb
17th March 2013, 19:35
I wouldn't rely on the papers to be 100% accurate.

Who is to say that written statements weren't given

Who's to say they were? The family seem to be dis satisfied, I am sure they know more than the papers.

DeV
17th March 2013, 20:22
Exactly, I assume the report is (at least) restricted which is why it is not available to the public.

Is it even made available to the families?

Helihead
17th March 2013, 20:55
Exactly, I assume the report is (at least) restricted which is why it is not available to the public.

That usually means someone has something to hide. This has nothing to to do with national security or "opsec" which is used as a get out of jail type card. When these things are kept from the public, which is wrong as they foot the bill, people smell a rat.

danno
17th March 2013, 21:13
In fairness the AC are neither unique nor innovative regarding restrictions on reports.Do the rounds of State Orgs,none make all internal reports fully public without any redaction.

Meatbomb
17th March 2013, 21:48
In fairness the AC are neither unique nor innovative regarding restrictions on reports.Do the rounds of State Orgs,none make all internal reports fully public without any redaction.

Example???
The Gardai even have their own Ombudsman's office.

danno
17th March 2013, 23:03
The garda ombudsman is an independant body like the AAIU.

The real Jack
17th March 2013, 23:50
The garda ombudsman is an independant body like the AAIU.

You cannot compare the powers of the AAIU to those of the Garda ombudsman. If the AAIU had similar powers this would not be happening.

sofa
17th March 2013, 23:56
In fairness the AC are neither unique nor innovative regarding restrictions on reports.Do the rounds of State Orgs,none make all internal reports fully public without any redaction.

The Tusker rock crash off Wexford in 1968. When the investigators went out to Air Lingus to take possession of the maintenance logs
of the Aircraft, They had mysteriously disappeared never to turn up again. So we just blamed the Brits.

danno
18th March 2013, 00:31
You cannot compare the powers of the AAIU to those of the Garda ombudsman. If the AAIU had similar powers this would not be happening.

I am not comparing powers of the aaiu wrt Garda Ombudsman,just highlighting that these are independant bodies whose reports are not internal reports such as a court of inquiry which under A5 is confidential.

The real Jack
18th March 2013, 00:43
I am not comparing powers of the aaiu wrt Garda Ombudsman,just highlighting that these are independant bodies whose reports are not internal reports such as a court of inquiry which under A5 is confidential.

What difference does their supposed independence make? One is a dickless report generating organisation the other can have people jailed. What's needed is somewhere half between the HSA & the GSOC. What does the DF gain by not publishing the results of this "court of inquiry"? What does the taxpayer gain by the DF being unaccountable wrt potentially avoidable ("non-operational") fatal accidents?

Meatbomb
18th March 2013, 00:45
I am not comparing powers of the aaiu wrt Garda Ombudsman,just highlighting that these are independant bodies whose reports are not internal reports such as a court of inquiry which under A5 is confidential.

What purpose does it serve to keep the findings confidential? National security? Or more like a desire to keep it all hush hush and not name and shame a few senior AC officers?
Not that it matters anyway as it seems some if the key players in the operation at that time were not called in and questioned.
Wa it true that written statements were Also given by some? And that questions were put to them in writing in advance?
Sounds like they really wanted to get to the bottom of the systemic failure alright!

The real Jack
18th March 2013, 00:46
DCOS OPs was GOC AC at the time?

Tadpole
18th March 2013, 01:25
Personaly I think that this reflects badly, not only on the Air Corps but on the Defence Forces in general. The IAC is a CORPS of the Irish Defence Forces not a standalone organisation.

Who provided aviation expertise to the CoI? The organisation under scrutiny???? Should this be a non aligned board, ie Army and Navy, assisted by a non IAC aviation expert (selected by the Army or Navy!!). In my opinion this crap again and again and again does nothing but expose IAC crews not only to accidents but to ultimate blame from their superiors when shit goes wrong. Don't they see that!! They will always be the scape goat!!!!

At the end of the day the IACs failing is the entire DFs failing. CoS, take control for God sake, there your personnel!

Jetjock
18th March 2013, 01:58
It's also a government failing. Just as the IAC is an arm of the DF, the DF is an arm of the State. It should not be a closed shop. When an organisation as small as the IAC self scrutinises and disciplines there's bound to be a certain amount of covering each others arses. Failure to impose control is a failure at departmental level.

All the while Shatter is off in Israel passing off personal political views as state policy.

DeV
18th March 2013, 03:44
Just so you know all CoIs are restricted (at least)!

danno
18th March 2013, 07:34
It's also a government failing. Just as the IAC is an arm of the DF, the DF is an arm of the State. It should not be a closed shop. When an organisation as small as the IAC self scrutinises and disciplines there's bound to be a certain amount of covering each others arses. Failure to impose control is a failure at departmental level....

Since the Gov also does not self scrutinise itself at political or civil service level in a meaningful fashion then one cannot expect better from sub units,not saying its right but there is a fine line between operating wrt risk of failure and fear of failure.

Meatbomb
18th March 2013, 09:41
If this were a large multinational company and some of its employees died in the performance of their duties and if the HSA found systemic failures as a contributory factor, like lack of oversight and not making sure SOP's and procedure was correctly followed, heads of that multinational may well be brought up on corporate manslaughter charges.
If this was a civil flight training operation we wouldn't even be having this discussion, heads would roll. To hide behind "opsec" and "military operations" is a smoke screen. Yes it was a military a/c on a VFR TRAINING FLIGHT.
We all remember the tragic loss of two firefighters in Bray in 2007. There is still a legal case pending that involves senior FF officers and County Council figures in Co Wicklow. One of the issues is that they were not provided with a safe working environment so as not to put employees at risk. It's is no doubt in relation to SOP's and training.
As for the PC9 crew, do they not have the same rights to a safe working environment???

http://www.breakingnews.ie/ireland/wicklow-county-council-to-face-trial-in-connection-with-firefighters-deaths-552597.html

Cesssenacavanman
18th March 2013, 10:36
If this were a large multinational company and some of its employees died in the performance of their duties and if the HSA found systemic failures as a contributory factor, like lack of oversight and not making sure SOP's and procedure was correctly followed, heads of that multinational may well be brought up on corporate manslaughter charges.
If this was a civil flight training operation we wouldn't even be having this discussion, heads would roll. To hide behind "opsec" and "military operations" is a smoke screen. Yes it was a military a/c on a VFR TRAINING FLIGHT.


Well does military law not do anything here? Does military law have any charges similar to corporate manslaughter? Or if your were responsible for making sure safety audits were done but didn't bother doing your job for 5 years can military do anything to you?

And Dev. I 100% believe what was first written in the papers and then brought up in the Dáil by Joe Higgins. OK maybe the papers can lie but I doubt a TD would in the Dáil! Also considering the Cadet's family are so dissatisfied with the report that they are going down the political route would suggest to me they have seen it!

DeV
18th March 2013, 12:10
if the HSA found systemic failures as a contributory factor


I assume you are claiming that the lack of safety audits and problems with authorisation of flights were a contributing factor to the PC-9 accident??

While they were found to be lacking, they were not found to have contributed to the accident !!!

Tadpole
18th March 2013, 13:07
Not following their own SOPs, in particular with reference to training did contribute to the accident. The lack of following SOPs is fully down to lack of oversight by the Unit OC, Flight Safety and at the head of the chain the GOC. Taking the view that systematic issues weren't pointed out in black and white by the AAIU (Read between the lines and they very much were) therefore they had absolutely no part in this accident is quite frankly nothing more than sticking your head in the sand and waiting for it to happen again. How the Defence Forces in general can condone this is quite frankly beyond me.

Meatbomb
18th March 2013, 13:16
I assume you are claiming that the lack of safety audits and problems with authorisation of flights were a contributing factor to the PC-9 accident??

While they were found to be lacking, they were not found to have contributed to the accident !!!

Well that's your assumption DeV!
Don't you think it's possible that if there were regular audits of FTS and if there was proper oversight that this accident may not have happened?
If I am on the range and I let off a round by accident? Who's to blame? Me? The Range officer that didn't bother to clear my weapon? Or the instructor that didn't train me correctly. Change any one of those and I might not have fired the ND.

Meatbomb
18th March 2013, 13:17
Not following their own SOPs, in particular with reference to training did contribute to the accident. The lack of following SOPs is fully down to lack of oversight by the Unit OC, Flight Safety and at the head of the chain the GOC. Taking the view that systematic issues weren't pointed out in black and white by the AAIU (Read between the lines and they very much were) therefore they had absolutely no part in this accident is quite frankly nothing more than sticking your head in the sand and waiting for it to happen again. How the Defence Forces in general can condone this is quite frankly beyond me.

Is this the way the DF conducts all its COI's? Not much point having them if that's the case

GoneToTheCanner
18th March 2013, 15:00
The D248 report was probably the most circulated report ever, in the Don's history of crash reports. They were always confidential, even being kept from serving personnel. A lot of what the enlisted troops knew/ know about accidents either came out because they witnessed it or tidied up afterwards. I was involved in tidying up after a few of them and was not privy to any accident reports; it was strictly Officer eyes only and even then, it was officer participants and Board members and designated postholders who got to see them. Is it the same in the case of Army and NS accidents?

regards
GttC

DeV
18th March 2013, 15:18
Not following their own SOPs, in particular with reference to training did contribute to the accident. The lack of following SOPs is fully down to lack of oversight by the Unit OC, Flight Safety and at the head of the chain the GOC. Taking the view that systematic issues weren't pointed out in black and white by the AAIU (Read between the lines and they very much were) therefore they had absolutely no part in this accident is quite frankly nothing more than sticking your head in the sand and waiting for it to happen again. How the Defence Forces in general can condone this is quite frankly beyond me.


Well that's your assumption DeV!
Don't you think it's possible that if there were regular audits of FTS and if there was proper oversight that this accident may not have happened?
If I am on the range and I let off a round by accident? Who's to blame? Me? The Range officer that didn't bother to clear my weapon? Or the instructor that didn't train me correctly. Change any one of those and I might not have fired the ND.

Are you talking about the AAIU report or not?

If you are, you must be more knowledgable than the expert INDEPENDANT AAIU !!
Who didn't find it to be a contributing factor !

The AAIU has no problem assigning contributing factors to the AC as D248 proved!

Meatbomb
18th March 2013, 16:43
Are you talking about the AAIU report or not?

If you are, you must be more knowledgable than the expert INDEPENDANT AAIU !!
Who didn't find it to be a contributing factor !

The AAIU has no problem assigning contributing factors to the AC as D248 proved!

I just asked do you think it's possible? The report pulled a few punches but that is only my opinion. From reading it I definatly felt a lot of similarities with the 248 report. System failures that were found to contribute to the accident.
The report into the PC9 may not actually state it but it can't not be a factor.

Tadpole
18th March 2013, 18:38
If you are, you must be more knowledgable than the expert INDEPENDANT AAIU !!
Who didn't find it to be a contributing factor !
Answer this Dev. According to your very blinkered view of the report if its not written down as a contributing factor then it has nothing to do with this accident. However, if the issues such as lack of oversight and lack of training in low level aborts had nothing at all to do with the accident why bother even putting them into the report at all?
FACT: They are in the report and there is very good reason for it....BECAUSE THEY WERE FACTORS....maybe not DIRECTLY contributing but contributing none the less otherwise the very knowledgeable, independent experts of the AAIU wont have wasted their time putting them IN THE REPORT!!!!

DeV
18th March 2013, 19:03
I just asked do you think it's possible? The report pulled a few punches but that is only my opinion. From reading it I definatly felt a lot of similarities with the 248 report. System failures that were found to contribute to the accident.
The report into the PC9 may not actually state it but it can't not be a factor.

It is the independent AAIU report, if they taught it was a contributing factor, they didn't!!!! Just because you think it is doesn't make it so, you cannot put words in the report!!!

By the way I may/may not agree with you but I will not put words in the AAIUs mouth!

Turkey
5th March 2014, 16:44
Following a court proceeding this thread has been reinstated.
For various reasons, we will be keeping a close eye on it, Members are reminded to respect the fact that 2 people lost their lives in this accident and left grieving families.
Members of the Air Corps are free to post here, but keeping their own identity from their superior/fellow officers and men is their responsibility alone.

Meatbomb
6th March 2014, 09:59
http://www.independent.ie/irish-news/courts/state-accepts-liability-in-the-death-of-air-corps-cadet-30047404.html

hptmurphy
6th March 2014, 14:19
Will the former COS be called to account to be asked why he blocked the progression of the investigation within the AC?

Jack Booted Man
6th March 2014, 20:06
Murph, interesting post, I can see why the mods suspended this thread , I assume you have very strong evidence for this allegation against a retired COS, hope he or his legal advisor aren't on IMO !

DeV
6th March 2014, 21:04
MOD: Lads this is serious and involves courts actions.

Unless there is evidence/reports in the public domain then it is not to be discussed here