I agree that due to loggers providing more evidence, there is an
opportunity to perhaps learn more and the ATSB should be informed of
this.
Was the spin in outlanding caused by leaving it too late to pick a
paddock, or by poor selection realised late and another paddock
picked in a hurry ? Was it flying over ountry and only just making
it to the other side ? Did the pilot have someone jibbering at
them on the radio ? Did they attempt a proper circuit ? Did they
attempt a circuit when there was no prospect of completing one ?
The list is endless.
However a logger won't tell you much about the above or the pilot's
intentions.
On 20/04/2007, at 7:03 AM, Matthew Gage wrote:
Slight correction for you. The BGA DO investigate ALL accidents and
incidents AND publish a report on all of them in their magazine.
The ATSB call in those that look of interest to them, or are likely
to be asked about by politicians - these have a more complete write
up - mostly because the investigator is paid to investigate, and is
not just another volunteer.
Sadly, too many of these look to be stall/spin accidents. Even more
unfortunately, we don't know what the real cause in each was, just
the last couple of factors.
They got too low, then too slow and spun with insufficient height
to recover. We don't know why they got too low in the first place,
and the pilots are not here to ask.
With the numbers of loggers and Flarms being fitted to gliders now,
we have a chance of looking in more detail at accidents. The ATSB
should be persuaded that although the accident looks to be the
same, because there is more evidence, there is a chance to better
understand causes.
We can then work on the full sequence of events that lead up to the
accident (through education and training). e.g. Was the spin in
outlanding caused by leaving it too late to pick a paddock, or by
poor selection realised late and another paddock picked in a
hurry ? Was it flying over unlandable country and only just making
it to the other side ? Did the pilot have someone jibbering at them
on the radio ? Did they attempt a proper circuit ? Did they attempt
a circuit when there was no prospect of completing one ? The list
is endless.
On 19/04/2007, at 11:48 PM, Christopher H Thorpe wrote:
It seems to me that most of us get to hear about accidents and
their likely causes quite soon after they happen, predominantly
through this forum. While I do not vouch for the accuracy of the
following recollection, I suspect it is not too far off the pace.
2004 Astir near Bendigo
· Tried to thermal away from low height on early (first?)
cross-country flight. Spun in from a height too low to recover.
2005 IS29 near Dalby
· Tried to thermal away from low height on a cross-country
flight in a glider in which the pilot had limited experience.
Spun in from a height too low to recover.
2005 Janus at Gympie
· Low in circuit on passenger flight. Passed up earlier
opportunities to land only to spin in from too low a height to
recover when attempting an outlanding.
2005 LS7 near Benalla
· Mid-air collision during lead and follow. Both pilots
aware of each other. Collision possibly due to misjudgement when
one joined the other in a thermal.
2006 Blanik at Lockhart
· Collision with winch wire. Non-standard circuit
procedures involving landing from opposite end to take-off while
winch was operating. Apparently no one identified the risk in
this practice.
2006 Alpin at Caboolture
· Non-GFA pilot trying to operate RAAus registered motor
glider in glider mode without appropriate training. Spun in from
a height too low to recover.
2006 Mosquito at Gulgong
· Stalled and spun off a winch launch.
2006 Stemme near Camden
· Mid-air fire, probably caused by leaking fuel hose.
Said to have occurred previously in this type.
2007 Pucatek at Keepit
· Overran runway into fence. As I recall, Bruce Taylor,
in a post at the time, related some possible causal factors.
The above is essentially a brief synopsis of what (If my
recollection is correct) happened. However, we are also
interested to know why each accident occurred so that we may take
the lessons on board to prevent a repeat. However, reading this
list one would have to notice that none of these accidents is new
– similar accidents have occurred in the past – so why haven’t we
been able to stop them?
In the above cases, did an accident occur because pilots pushed
the margins? Were they distracted, or suffering an illness, or
became incapacitated? Was it over confidence, inexperience or
poor training? Was it weather/environment related? Was it
airworthiness related (like the Stemme accident)? The list goes on!
In many cases we are unlikely to ever know the real reason why
these accidents occurred or the factors leading up to it. On the
other hand, there will be some cases where it is quite clear why
the accident occurred and then we need to consider was there
culpability, ineptness, unforeseen circumstances, or other “human
factors” at work.
It is unrealistic to expect such in-depth analysis of such very
basic accidents. It is also unrealistic to expect someone within
the GFA to pen a report for all to see pointing blame at a
particular individual or organisation, for in the end any such
analysis is mostly an hypothesis and open to challenge or litigation.
Someone earlier mentioned the UK, USA and German gliding
authorities publish accident reports. If you take the time to
look, you will notice these reports are provided by the AAIB, NTSB
and the German Ministry of Transport – the foreign equivalents of
the ATSB. I do not see the National Soaring body authoring
these. In Australia, accident reports produced by the ATSB are
subject to certain legal privileges that protect the authors and
cannot be used against individuals or companies for any role they
may have played in a transport safety occurrence. The GFA is not
afforded and cannot provide such protection.
To quote the ATSB…”Because many accidents are repetitive in
nature, investigating these in any detail may not be justified,
given the bureau’s limited budget. In such cases, the ATSB will
not necessarily attend the scene, conduct an in-depth
investigation or produce an extensive report.” Gliding accidents
tend to fall into the category of “repetitive in nature”, so the
lessons should already be known.
I must disagree with the assertion that the GFA is doing nothing
to alert members. In fact, GFA is actively reviewing and
analysing accident data – or do you really believe your RTOs
merely file accident reports? The results can be seen in the new
series of Operational Safety Bulletins issued from time to time.
The Safety Seminars are also used as a forum for disseminating
such information and are open to all members, albeit it is
acknowledged that not every member is able to attend. Similarly,
discussion is also had at the NGS Seminars. Through these various
mediums the message should be filtering through.
And as for our Queensland members, I recall the GFA president
recently provided them with a specific presentation on accident
statistics and what the GFA was doing. Hardly “Silence” as Jeremy
would have us believe.
Christopher Thorpe
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