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ATSB reports, CASA and the ABC Chopper

The following is a summary by pprune of the sad loss of the ABC reporters and the AS355 at MArre over 2 years ago. ATSB takes, as Phillipa McDonald says, over 2 years and 3months later.

 Posted Thu 14 Nov 2013, 12:22pm AEDT

 The Australian Transport Safety Bureau has found that spatial disorientation was a major factor in the crash of an ABC helicopter in 2011.

Pilot Gary Ticehurst, cameraman John bean and reporter Paul Lockyer who were onboard were killed, and investigators are calling for major changes to regulations that govern flying in extremely dark conditions.


Source: ABC News | Duration: 2min 27sec


Topics: air-and-space, abc, australia, sa


Full Summary from pprune:

14th Nov 2013, 10:48   #48 (permalink)
Join Date: May 2010
Location: More than 300km from SY, Australia
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atsb – Reports

The ABC chopper report has been released

Investigation: AO-2011-102 – VFR flight into dark night involving Aérospatiale, AS355F2 (Twin Squirrel) helicopter, VH-NTV, 145 km north of Marree, SA on 18 August 2011

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Old 14th Nov 2013, 13:06   #49 (permalink)
Join Date: Apr 2007
Location: Go west young man
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Finally..only took 27 months!!

Not too many surprises there I guess??

It is interesting that the ATSBeaker have issued yet another SR (AO-2011-102-SR-59)to Fort Fumble, that would be 5 for 2013. Considering prior to March (refer here: Safety Recommendations for 2013) there was only one SR issued to FF within the last 5 years, that is somewhat of a world record for ATSBeaker.

Speaking of Beaker just heard him mi..mi..mi-ing on the wireless talking about that particular SR (above)…hmm wonder if he is aware the two mentioned in my previous post have expired???

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Old 14th Nov 2013, 23:10   #50 (permalink)
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Nice pick up Sarcs. No doubt Beaker is churning out the work knowing for several months now that his mi mi mi empire would end up coming under the spotlight. I’m still looking forward to the Canadians releasing the results of their review next year. Not sure why though as nothing will get done with the findings.
It will be interesting to see the outcome of Truss’s initiative next year with the ‘independent’ review. No doubt the report will be handed to the minister in which the government will respond to each recommendation with ‘the government acknowledges that recommendation’. The usual carefully crafted responses in which the government doesn’t actually agree to implement any changes, it just acknowledges that changes have been recommended.
Political school of bullshit 101.

Time will tell, but none of this would have been made possible without the growing number of IOS (and don’t forget that Mr Truss’s international panel of experts will themselves receive the opportunity to earn an honorary place among the IOS), or without the savvy Senators who have refused to allow polish to be applied liberally to the turd.

I would recommend that the review panel spend time with the good Senators and discuss the mystique of Australian aviation with them. I suggest Senator Nash’s office, that way they can meet pot plant Pete.

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Old 14th Nov 2013, 23:26   #51 (permalink)
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A positive spin.

CASA and ATSB make ASA look outstanding

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Old 15th Nov 2013, 07:06   #52 (permalink)
Join Date: Oct 2010
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No more spinning – I’m dizzy.

Well, in all probability, the pilot probably stacked the chopper, we probably should have sent the insurance investigator (QBE 1) who would have probably made it probable that the chopper was probably pranged. But no matter CASA will probably redefine “probable darkness” and all will probably be well. But it’s probable that we have conned the ABC, probably shut down the probability of bad press, which cannot in any probable cause case, end up with my resignation.

Mi Mi “That’s a great relief, glad we have the beyond reason probability model and a simpering nodding interviewer who probably swallowed the guff”.

Long live short reports, long waits and great KPI bonuses. Thank the gods for the remote control button, new TV’s are expensive.

Last edited by Kharon; 15th Nov 2013 at 07:08. Reason: Manfully ignoring the “pukey’ icon, that’s why.

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Old 16th Nov 2013, 17:30   #53 (permalink)
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Linking the links i.e. accident(s) causal chains (back to reason)!

Having now read the report (AO-2011-102), scrolled through numerous media articles and video coverage, including the ABC 7:30 report (Report on ABC helicopter crash urges overhaul of regulations), I’m quite disturbed by some very interesting parallels coupled with some déjà vu(flashbacks) to episodes in the Senate Inquiry and previous Senate Estimates.

{Note: The 7:30 vid is well worth watching but warning you’ll have to put up with large sections of Beaker fumbling along mi..mi..mi-ing. However it is not quite as bad as his appearances at the Senate inquiry/Estimates or the ‘head buried in the sand’ interview on 4 corners..see here- 4C Beaker interview}

So for a setting the scene here’s a quote from the 7:30 Report transcript(my bold):

PHILIPPA MCDONALD: The crash and subsequent fire was so intense that Air Transport Safety investigators feared they’d never determine exactly what happened. But an intense two-year forensic investigation uncovered far more than ever anticipated, with vital information provided by the United States Army Aeromedical Research Laboratory.

MARTIN DOLAN: One of the key things they did for us was to feed into some modelling of human perception the flight data that we had for this flight which showed that the sort of increasing bank associated with this helicopter and this accident would probably until very late in the stage not have been detectable without visual reference or without reference to instruments.

PHILIPPA MCDONALD: Investigators believe the pilot experienced what’s called spatial disorientation. In the dark of night, with no visible horizon, he couldn’t recognise the chopper’s spiralling descent in time to recover.

Fellow chopper pilot and friend, David Wilson, knows how spatial disorientation can unhinge the senses.

DAVID WILSON, CHANNEL NINE PILOT: I don’t think there’d be a pilot out there today who couldn’t say he has never suffered from spatial disorientation. It’s a matter of firstly recognising it and then doing something about it because it fights all your senses. You think you’re sitting bolt upright, whereas you’re actually leaning at 45 degrees.

PHILIPPA MCDONALD: Gary Ticehurst was considered one of the nation’s best helicopter pilots and was qualified to fly under the conditions that night. But the Australian Transport Safety Bureau says this tragedy shows aviation regulations need to be tightened.

MARTIN DOLAN: We’re saying we’re not sure that flight in dark-night conditions, that the standards of safety are necessarily at the level they should be and we’re asking the Civil Aviation Safety Authority to take a close look at that.

PHILIPPA MCDONALD: The Civil Aviation Safety Authority says things will change. In future, all helicopters flying at night with passengers will have to be fitted with an autopilot or have a two-pilot crew.

This is where the neurons started pinging around, so I then referred to the report and in particular Appendix F – Accidents involving night VFR operations. In table F1 (halfway down the page) there was this entry:

17 Oct 2003
Bell 407 helicopter, VH-HTD, aerial work (emergency medical services) en route from Mackay to Hamilton Island, Qld. Loss of control en route. Dark night conditions. 3 POB, all fatally injured.

It was then that it all started to gel and drew my attention to a recent post from PAIN post #34 , that linked to some working notes and this is where it gets interesting , from the PAIN notes:


1) CFIW: East of Cape Hillsborough, QLD, Bell 407, VH-HTD; 17 October 2003.

Report – R20050002.
Issue date 14 March 2005.
Recommendation R20050002
As a result of the investigation, safety recommendations were issued to the Civil Aviation Safety Authority recommending: a review of the night VFR requirements, an assessment of the benefits of additional flight equipment for helicopters operating under night VFR and a review of the operator classification and/or minimum safety standards for helicopter EMS

ATSB Safety Recommendation.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review it’s operators classification and/or it’s minimum safety standards required for helicopter Emergency Medical Services operations. This review should consider increasing; (1) the minimum pilot qualifications, experience and recency requirements, (2)
operational procedures and (3) minimum equipment for conduct of such operations at night.

Ok so if you then download the 2003 ATSB report (link above) and put that report alongside the AO-2011-102 report you will see some remarkable parallels..especially in the areas that deal with spacial disorientation and in the Safety Actions/Recommendations section (pg 71 onwards from 2003 report).

{Hmm..kind of makes you wonder why the ATSBeaker needed to rely on the United States Army Aeromedical Research Laboratory when they had already done the hard work back in 2003.}

On a final note here is a quote from the PAIN working notes from Coroner Henessy’s findings/recommendations:


16. The Coroner supports CASR draft regulations point 61 and 133 becoming final.
17. That beacons, both visual and radio, be placed on prominent and appropriate high points along routes commonly utilised by aero-medical retrieval teams, including Cape Hillsborough.
18. The Coroner supports the ATSB recommendations 20030213,and promulgation of information to pilots; 20040052, assessment of safety benefits of requiring a standby altitude indicator with independent power source in single pilot night VFR; 20040053, assessment of safety benefits of requiring an autopilot or stabilisation augmentation system in single pilot VFR; and R20050002, review operator classification and minimum safety standards for helicopter EMS operations.

Starting to join the dots?? More to follow..Sarcs (K2)


CASA SRs for AO-2011-102: AO-2011-102-SI-02 , AO-2011-102-SI-03

CASA SRs for air200304282: R20040053,R20050002, R20010195, R20030213.

Note: With the courage of their convictions and experience, you will note that the bureau of old issued R20030213 within a month of the accident.. compare that to ATSBeaker…27 months was it??

Last edited by Sarcs; 16th Nov 2013 at 18:14. Reason: Addendum: SR Links

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Old 16th Nov 2013, 19:51   #54 (permalink)
Join Date: May 2010
Location: More than 300km from SY, Australia
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casa is out of touch with the Aviation Industry and so is mccormick

Good brief sarcs.

The following is the history of the PART 133 [seven years have passed in this one, since the atsb SR] and still not complete, yet casa are loading the industry with a bunch of rubbish regs in this process:

CASR Part 133 – Australian air transport operations – rotorcraft –
Consultation history

Consultation updates in 2012 CASR Part 133 – Consultation Draft of CASR Part 133 – Australian Air Transport Operations – Rotorcraft Comments now closed.

26 Jun 2012 Briefing on CASR Part 133 – May 2012 Updated briefing on CASR Part 133 – May 2012

17 May 2012 Consultation updates in 2009 NPRM 0811OS – Passenger Transport Services, International Cargo and Heavy Cargo (above 8640kgs MTOW) – Rotorcraft This NPRM is now available.

6 May 2009 Consultation updates in 2008 NPRM 0807OS – Passenger Transport Services: terminology in and application of new CASR Parts 119, 121, 129, 131, 133 and 135 This NPRM closed for comment on 6 February 2009.

11 Dec 2008 Consultation updates in 2003 NPRM 0301OS – Air Transport and Aerial Work Operations – Rotorcraft NPRM 0301OS – Air Transport and Aerial Work Operations – Rotorcraft has been published. Your comments are invited by 30 May 2003.

27 Mar 2003 Consultation updates in 2002 MOS Part 133 – Air Transport & Aerial Work Operations – Rotorcraft Draft Chapter 11 titled Airworthiness and Maintenance Control to Manual of Standards – MOS Part 133 – Air Transport & Aerial Work Operations – Rotorcraft, has been published. Your comments are invited.

6 Aug 2002 Consultation updates in 2001 New technical working draft regulations for CASR 133 maintenance aspects CASR Part 133 maintenance aspects of the regulations have been developed and are available for review.

18 Oct 2001 Consultation updates in 2000 DP 0006OS – Commercial Air Transport Operations — Rotorcraft DP 0006OS – Commercial Air Transport Operations — Rotorcraft response period has been extended to close on 31 January 2001.

6 Dec 2000 DP 0006OS – Commercial Air Transport and Aerial Work Operations – Rotocraft DP 0006OS – Commercial Air Transport and Aerial Work Operations – Rotocraft has been published. Your comments are requested by 8 December 2000.

And still not finished

From the atsb site:

Recommendation issued to: Civil Aviation Safety Authority

Output No: R20050002 Date issued: 14 March 2005 Safety action status:

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Unread 17th Nov 2013, 05:25   #55 (permalink)
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 1,229
Post of the year award.

Can someone make sure the idiot reporters at the ABC get a copy of Sarcs # 53 where he does their job for them, properly and almost writes their story. What a sorry tale ABC investigative journalism makes, how sad that our national “razor sharp” press cannot research and develop a story that is very much in the nations interest. Why would they bother, it’s probably more self indulgent and PC to publicly weep and wail over a lost comrade, rather than to try to understand why he’s dead, why the ATSB and CASA are full of it and why entire industry is seriously pissed off. Wakey wakey Aunty….

I’ll stick my neck out and say that the Sarcs post more clearly defines, in one page the need for reform than all the bloody awful polly chatter, CASA waffle and ATSB probability statements ever printed. Nicely played Sarcs, please accept my vote for the post of the year award. Bravo……Indeed, well done sirrah.


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