IAC 265 report?

BantryRebel

Long time lurker, just registered so i could ask a question.

What is the story with the report on the PC-9m crash where two officers were killed in Co.Galway. Just checked on the AAIU website and the pre-lim report was out nearly two years ago! Am I wrong in thinking that is an unusual long amount of time for the full report not to be out yet considering the prelim only took a couple of months? Could anybody working in aviation indusrty shed some light on this?

Regards,
Joseph.

xflyer

Well it's being investigated by Air Corps officers. So the delay is down to them. It should be due shortly though.

As to what happened, controlled flight into terrain after flying up the wrong valley in poor visibility is the obvious conclusion.

How and why it happened is no doubt the crux of the report.

Chicken1

BantryRebel wrote: »

Long time lurker, just registered so i could ask a question.

What is the story with the report on the PC-9m crash where two officers were killed in Co.Galway. Just checked on the AAIU website and the pre-lim report was out nearly two years ago! Am I wrong in thinking that is an unusual long amount of time for the full report not to be out yet considering the prelim only took a couple of months? Could anybody working in aviation indusrty shed some light on this?

Regards,
Joseph.

You seem very interested in the report, why would you want to know what happened, it does not matter how long it takes as long as the correct cause of the accident is estabilished.

BantryRebel

xflyer wrote: »

Well it's being investigated by Air Corps officers. So the delay is down to them. It should be due shortly though.

As to what happened, controlled flight into terrain after flying up the wrong valley in poor visibility is the obvious conclusion.

How and why it happened is no doubt the crux of the report.

But I thought the AAIU are handling this one, or was that changed during the process? I just remember reading in the papers at the time that the air corps would have no role in the investigation.

BantryRebel

Chicken1 wrote: »

You seem very interested in the report, why would you want to know what happened, it does not matter how long it takes as long as the correct cause of the accident is estabilished.

Well i had came across the thread on the prelim report here and a few posters seemed to already know that it was CFIT in November 2009. That's what sparked my curiosity. Considering the crash happened in september/october 09 it seems very strange that the final report hasnt been issued yet.(But that's just the tinfoil hat person coming out in me).

The point of a report is to save lives. So if the investigation isn't being carried out as quickly as it can, then those responsible are putting other pilots in danger.

FlutterinBantam

xflyer wrote: »

Well it's being investigated by Air Corps officers. So the delay is down to them. It should be due shortly though.

As to what happened, controlled flight into terrain after flying up the wrong valley in poor visibility is the obvious conclusion.

How and why it happened is no doubt the crux of the report.

Unfortunately they flew into the cloud lined with stone, sad event, hope the report will make a difference.

dechand

Very interesting new thread, in response to xflyer, where did you get the info that it was cfit after flying up the wrong valley? ive checked the prelim report on the AAIU site and that info is not there?
Are you on the inside ? go on tell us more.

Delancey

I had presumed that accidents involving military aircraft are investigated by the Air Corps and not by AAIU ?

dechand

No when i checked on the AAIU site earlier today it said that it was a joint investigation by the aaiu and the IAC.
Dont know what the reason for that was , but reading the prelim report it states that there was no defect found on the aircraft. so what conclusions can be drawn from that then.?

BEASTERLY

Delancey wrote: »

I had presumed that accidents involving military aircraft are investigated by the Air Corps and not by AAIU ?

This one was given to the AAIU because of the farce that the investigation into the SAR Dauphin turned out to be. The hope being that vested interests wouldn't influence this one.

Delancey

BEASTERLY wrote: »

This one was given to the AAIU because of the farce that the investigation into the SAR Dauphin turned out to be. The hope being that vested interests wouldn't influence this one.

First time I''ve heard of shortcomings in that accident report - in what aspects did it fall short ?

dechand

Is that report available on line also like the pilatus pc9 crash ?
The pc9 crash report was released very soon after the crash wasnt it?.But there not much detail in it , are those planes fitted with the black box recorders as they are fairly new .

BEASTERLY

Delancey wrote: »

First time I''ve heard of shortcomings in that accident report - in what aspects did it fall short ?

Didn't the air corps investigation take an unusually long amount of time?

Klunk001

BEASTERLY wrote: »

Didn't the air corps investigation take an unusually long amount of time?

Accident happened 1st July 1999, report published by the AAIU 21st August 2000.

http://www.aaiu.ie/AAIUviewitem.asp?id=13091&lang=ENG&loc=1280

dechand

wow! that was very quick ,or maybe it wasnt.
How come the pilatus pc9 crash has even come out after more than two years?
I have since learned that those pc9ms are fitted with the black boxes , seems odd that it would take so long to produce a report considering all the information they would have.
Did the black boxes survive or were they lost in the explosion that happened.?

BEASTERLY

Klunk001 wrote: »

Accident happened 1st July 1999, report published by the AAIU 21st August 2000.

http://www.aaiu.ie/AAIUviewitem.asp?id=13091&lang=ENG&loc=1280

I stand corrected, i seem to remember a report into the accident only coming out 4 or 5 years ago? Maybe it was a report into procedure or something rather than the crash?

Stovepipe

Hi all,
It has been mentioned in the latest Flying In Ireland magazine that the draft report has just been circulated to interested parties for comment, so when it has been read by them and replies given, it will be published, which, in my experience, will be within a few months, possibly early Spring.

regards
Stovepipe

dechand

Thanks for that info stovepipe , didnt know that when the AAiu made a finding that third parties had the opportunity the make comments or observations on their investigations.
I presumed that it was like some kind of garda investigation.
What kind of third parties would there be to make these comments.

Stovepipe

Hi there
What happens is that the draft report is sent to all involved parties after an accident and, in the event of a fatality, the next of kin, for comment.For example, if a Flying Club aircraft has an accident, then the pilot (assuming he or she has survived), the Club, the serving ATC unit and the IAA will all get a draft copy. If an accident happens on an airfield, then the airfield operator and even his fire crew will get one, especially if they were deployed. Essentially, anyone who is party to an accident gets invited to comment, to ensure that the final report is accurate. It's not unknown for several drafts to appear before the final one. In the case of 265, the Air Corps is obviously involved but I'd imagine Pilatus are also there, by default of being the manufacturer. It's also common for individual manufacturers of sub components, such as engines, to be involved.

regards
Stovepipe

dechand

thanks for your help on that , I and others i presume ,never realised the complexity of the detail involved in an investigation like this, If every sub component mfr is implicted in an accident it may a very long time indeed.
Do you know if the black boxes were readable after the explosion in the Galway crash?

xflyer

dechand wrote: »

Very interesting new thread, in response to xflyer, where did you get the info that it was cfit after flying up the wrong valley? ive checked the prelim report on the AAIU site and that info is not there?
Are you on the inside ? go on tell us more.

No, it was all from the reports at the time. As far as I recall the original plan was to fly to Maam which is in a wide valley. However the crash happened one valley up from that. Given the conditions an easy mistake to make. A mistake that many a pilot has made in one form or another over the years.

No doubt it will be fully addressed in the report.

dechand

I take it from your information then and coupled with the AAIU report that there was no fault on the aircraft, that this was a case of pilot error .
Do you know which pilot was flying ? one of them was a very experienced instructor and display flyer and the other a student.

Storm 10

dechand wrote: »

I take it from your information then and coupled with the AAIU report that there was no fault on the aircraft, that this was a case of pilot error .
Do you know which pilot was flying ? one of them was a very experienced instructor and display flyer and the other a student.

Are you for real, do you think anyone here is going to say who was flying, its nothing to do with us or you, wait for the report and stop speculating.

xflyer

No dechand, you can't say there was no fault with the aircraft. There may indeed have been a fault with the aircraft which may have contributed to the accident. That the whole point of accident investigations. Even if the answer seems obvious and we laymen have the luxury of leaping to a conclusion. An accident investigator doesn't. He must eliminate all other possible causes and also examine any chain of events that led to the accident. That's why they take so long.

It's is too easy to say pilot error, there may have been other factors, distractions, instrument failures or an error in planning. A series of causal links in a chain that leads to disaster. There's never just one reason for accident, any accident.

We cannot even be sure who was flying it. The assumption must be that it was the student, after all that's the reason for the flight. But it could have been the Instructor who may have taken control. That no doubt will be dealt with in the report.

That's why any accident report is worth a read by any pilot, better to learn lessons by proxy than for real.

dechand

was the aircraft to land in mamn so .?if that was intended destination ,
It appears that certain folk have a lot more information on this incident that is published in the report that was made public in Nov 2009.

Storm 10

dechand wrote: »

was the aircraft to land in mamn so .?if that was intended destination ,
It appears that certain folk have a lot more information on this incident that is published in the report that was made public in Nov 2009.

Cant understand why you want to know so much about this sad incident, wait for the report and stop fishing for info that more than likely is wrong. Wonder if our troll is back again??????????????

xflyer

Hardly dechand, it was all published in the media at the time. You just weren't paying attention. Maam was just a checkpoint on a navigation exercise. They were supposed to land in Galway afterwards.

Klunk001

http://www.kildarestreet.com/debates/?id=2011-10-06.336.0#g337.5


Dáil debates
Thursday, 6 October 2011

What are Dáil debates?
Topical Issue Debate
Air Accident Investigations

All Dáil debates on 6 Oct 2011
« Previous debateNext debate »

4:00 pm
Willie O'Dea (Limerick City, Fianna Fail) Link to this
I am grateful for the opportunity to raise this important matter in the Chamber today. Next Wednesday will mark the second anniversary of a dark day in the lives of two decent families, because 12 October 2009 was the day on which an Air Corps aircraft on a training flight crashed at Cornamona , west County Galway, resulting in the deaths of two of the Air Corps’ best and brightest, namely, instructor Captain Derek Furniss and Cadet David Jevens. I was Minister for Defence at the time and recall well the scene at Baldonnel aerodrome as the coffins were brought in late at night, as well as the sense of shock, anguish and helplessness that permeated the entire defence community and people further afield. These scenes were repeated in no small measure at the funerals over the next couple of days, both of which I attended.
Obviously neither I, as Minister for Defence, nor the defence community nor anyone else was in a position to bring the two young men back. At the time, however, we promised their families that we would set up immediately an investigation by the air accident investigation unit, which would investigate the causes and the reason this happened and would explain this fully to the families by way of publishing a report at the earliest possible opportunity. The intention was to enable a measure of closure to be brought to the families, which have suffered greatly as a result of this unfortunate incident.
Records will show that when an investigation of this type is established, it usually takes a year to investigate the matter and come to the final report, which then is published. In this case, two years will have elapsed next Wednesday and yet the final report has not been published. Moreover, I am sorry to state the lines of communication between the Air Corps and the Department of Defence and the families of the two - or certainly the family of Cadet Jevens - are minimal to say the least, which greatly disappoints me. The usual procedure is that a draft report is prepared and given to all the interested parties to read. Thereafter, any interested party within this country has 30 days in which to make an observation on the matter, while parties outside the country, usually the manufacturer of the aeroplane, have 60 days in which to communicate.
The draft report was not given to the families until 14 July last, which was 21 months after the accident. Observations were made and the matter literally has been in limbo since. The Jevens family, which has spoken to me about this matter, is suffering the greatest anguish. It is unimaginable and no words of mine could adequately do justice to the anguish and trauma that family has suffered as a result of this incident. Moreover, this has been exacerbated out of all proportion by the delay in publishing the report. Consequently, I ask the Government to publish this report. While the Jevens family will never get over the loss of young David - his younger brother’s main ambition in life now is to join the Air Corps - they need some closure and this is the only closure the State can offer to them. As more than double the usual length of time has elapsed and the second anniversary of the accidents falls next Wednesday, I ask the Government to undertake to either publish the report immediately or to give me a good reason it cannot be published.
Add your comment
Alan Kelly (Tipperary North, Labour) Link to this
I am pleased to take this opportunity to speak on behalf of the Minister for Transport, Tourism and Sport, who is attending a European Union Transport Council meeting today, on the subject of the final report regarding the accident to the Air Corps PC-9(M) training aircraft at Cornamona, County Galway, on 12 October 2009. On behalf of the Minister, the Department and myself, I express my deepest sympathy to the families, friends and colleagues of Captain Derek Furniss and Cadet David Jevens, who lost their lives in this tragic accident.
At the time of this accident, the Deputy was Minster for Defence and with the then Minister for Transport, he agreed the investigation of the accident would be conducted by the air accident investigation unit of my Department in accordance with Regulation No. 27(1) of SI 205 of 1997, Air Navigation (Notification and Investigation of Accidents and Incidents) Regulations 1997. Three senior officers of the Air Corps were assigned to the air accident investigation team. A preliminary report on this accident was issued and published by the air accident investigation unit on 17 November 2009.
Following a complex and detailed investigation and in accordance with Regulation No. 18 of SI 205, a notice of findings that included a draft report on the accident was issued on 14 July 2011 to all interested parties associated with the accident. These interested parties included the families of both deceased pilots, the Department of Defence, the Air Corps, the state of the manufacturer of the aircraft, that is, Switzerland and the manufacturer of the aircraft, namely, Pilatus. All parties made formal comments, one of which was a substantial legal submission. These submissions required detailed consideration and a response from the air accident investigation unit in accordance with the requirements of notice of findings, Regulation No. 18(1)(c) of SI 205.
An additional factor that has contributed to the delay in finalising the report is the provision of the significant resources required to deal with the international commitments associated with the fatal accident involving a public transport aircraft at Cork Airport on 10 February in which six people lost their lives and six others suffered injuries. However, I am pleased to be able to inform the Deputy that the Air Accident Investigation Unit has advised me that its response to the submissions received is nearing completion and that the release of the final report is imminent.
Add your comment
Willie O'Dea (Limerick City, Fianna Fail) Link to this
I thank the Minister of State for his positive response. He will appreciate, however, that the delay cannot be justified. It took 21 months to get the draft report and now, two years on, the final report has not yet appeared. In the meantime the family is suffering tremendous anguish, pain, sorrow and a sense of loss. I have done my best to communicate to the Government the urgency attached to bringing closure to the matter. I am delighted that the Minister of State has told me that publication of the final report is imminent. While we will not hold him to it, perhaps he might like to venture an approximate timescale within which the family can expect to receive the report.
Add your comment
Alan Kelly (Tipperary North, Labour) Link to this
I agree with the Deputy. The Government wants to bring closure - whatever closure might mean, as it is a word that is often used - for the families in their loss. I accept that they have endured considerable suffering. As I said, a substantial legal submission needed due consideration for a number of reasons which I will not detail. However, I assure the Deputy release of the report is imminent; it will be published in a very short period of time.

dechand

Ok guys steady on ive just got a curious mind , seeing as it happened over 2 years ago there seems to be little info on it , apart from what was out at the time .

Stovepipe

@dechand,
Obviously not every single manufacturer of every subsystem and minor component is involved in an air accident investigation, but it's quite common for the airframe and engine manufacturers to be represented. Interested parties are also allowed to be included, if they feel that they might have an input or might be mentioned in the accident report, such as avionics manufacturers contacted by the crash investigators or the airframe manufacturer. In some cases, the AAIU can request/demand that an organisation or even a State send a representative or demand/request information, such as weather reports or ATC tapes and so on.
every possible lead is chased down, which is why accident investigations take so long.

regards
Stovepipe

dechand

Whats the story on this incident then , im gettin conflicting views and opinions , when are the board of enquiry gona publish the findings.

Stovepipe

I'm after tellin' ya! the draft has gone out for comment and the final report will arrive in a few months.Ring the AAIU if you don't believe me.

regards
Stovepipe

Klunk001

The plot thickens, minister bans release of report.


http://www.irishtimes.com/newspaper/ireland/2011/1210/1224308870048.html

westdub

Typical Journalism... The release of the report is stopped because of a appeal so the Minister has by law to stop the release until the appeal is over , The headline "Minister delays release of report" would be more accurate, But when did accuracy ever bother a journalist....:rolleyes:

His ban on publication followed the application of a previously unused clause in Irish air-crash legislation. It was invoked by an appeal lodged by a so-far unidentified person.

“One of the interested parties is appealing. The department is precluded from providing any further information regarding their identity,” a spokesperson for Mr Varadkar said. “We cannot comment on the grounds of appeal. However, the grounds to seek a notice of re-examination are set out under part III, section 19 of the SI 205 of 1997.”

Section 19 allows for an appeal for a re-examination if a crash report’s findings “appear to reflect adversely on the person’s reputation or on the reputation of any person, living or dead”.

BantryRebel

Looks like my orginal question was awnsered so! Also heard a piece about the delay in the report on drivetime on Radio 1 yesterday evening, only caught the end of it but pretty much to the same effect as the article. Seems very odd that you can delay a report for the sake of a deads person reputation all the same. I think the fact that the cadets parents said they want it to be released as soon as possible might be a hint at the contents of the report.

Oh I do love a good conspiracy!

xflyer

It doesn't take much to work out what's happening here. I'm sure the person involved has the right motivation in their attempt to protect their loved one's reputation. But I'm afraid it will have the opposite effect.

The report's job is not to apportion blame but sometimes the facts speak for themselves. `

I wonder in fact if this report can be delayed indefinitely if an interested party refuses to approve it's finding after appeal. If so it's a bad day for air safety in Ireland.

dechand

The articles in todays Indo and Times seem to put things across in a smoke and mirrors way, its only when one reads them properly that the smokescreen begins to clear a little,
The final report when or if it is published will make some interesting reading , especially if matters are so fraught at the present.

Dochealth

dechand wrote: »

The articles in todays Indo and Times seem to put things across in a smoke and mirrors way, its only when one reads them properly that the smokescreen begins to clear a little,
The final report when or if it is published will make some interesting reading , especially if matters are so fraught at the present.

The report may have conclusions relating to safety culture at AC...

dechand

Ah I think I can see where this is going.!

Delancey

I can recall 5 different fatal accidents involving Air Corps aircraft - any stats available as to the general safety record of the Air Corps ?
Difficult I know to compare them with ' real ' Air Forces but just wondering how they are on safety.

NewSigGuy

I think all AC fatal accidents have been CFIT.. I may be wrong but also quite a few non fatal accidents, serious incidents could be attributed to the same cause.

Its not unreasonable to question the Safety Culture given the propensity for CFIT

roundymac

For the uneducated amongst us, CFIT????

eatmyshorts

roundymac wrote: »

For the uneducated amongst us, CFIT????

Controlled Flight Into Terrain.
a.k.a flying a perfectly functioning aircraft into the ground.

xflyer

I think the Air Corps is relatively safer than other air arms. But that's because they don't really fly at the same intensity as more 'operational' air arms. I remember a statistic years back in relation to the Alouettes. According to Aerospatiale over the time they were in service the Air Corps should have lost 20 helicopters. In fact they only ever had eight and only lost one in a non fatal accident. On the face of it, that's good and reflects well on the Air Corps safety culture. In reality it's more to do with the fact that there wasn't much in the way of real military operations. The riskiest part was SAR and that was kept to day VFR close to the coast.

It's the same with the rest of the Air Corps. They're rarely deployed away from Baldonnel and never get sent abroad or operate out of austere environments.

As for recent accidents, there are very few CFIT. The PC9 was clearly CFIT. The Dauphin years ago was CFIT but there were other factors. The most recent Cessna crash wasn't CFIT. It was an example of a young pilot showing off for his buddies. History is littered with examples of that kind of accident. Two of Marchetti accidents involved cadets mishandling their aircraft and spinning in fatally, probably unauthorised aerobatics. Another Marchetti crash involved a cadet changing fuel tanks improperly during a simulated engine failure which rapidly turned into a real engine failure. There were others too but the last real CFIT was back in the early fifties when a Seafire hit Corrig Mountain in Wicklow.

So it isn't a big factor. I think their safety record stands up well.

RadioRetro

This email from the Dept. of Transport just dropped into my mailbox;

"Statement on the report into 2009 fatal Galway Air Corps accident

On 12th October 2009 an Air Corps aircraft crashed in Co. Galway, causing the deaths of a flying instructor and a student cadet.

The Air Accident Investigation Unit (AAIU) of the Department of Transport, Tourism & Sport published a Preliminary Report into the accident in November 2009, and has since completed the Final Report.

The Final Report was due to be published on November 8th of this year. However, the legal representative of one of the families has sought a review of this Report under Part III, Section 19 of Statutory Instrument 205 of 1997.

Given that this is a sensitive matter which concerns two bereaved families, and on foot of advice received from the AAIU, Minister Varadkar felt it reasonable to give consideration to this request.

The Minister subsequently ordered an internal review of the findings, to be conducted by an official in the Department who is not connected with the AAIU. The Minister has also sought the advice of the Attorney General on the matter. Publication of the report has therefore been deferred, but has not been halted.

This review will be completed within a few weeks, at which point a decision is due to be taken regarding publication.

The Final Report has been made available to all interested parties. Any safety recommendations arising from the investigation have already been made available to all appropriate bodies and are being acted upon.

Ends"

Bearcat

I think the report is damning hence the pin was pulled. We'll see.

Very sad for all concerned.:(

NewSigGuy

xflyer wrote: »

I think the Air Corps is relatively safer than other air arms. But that's because they don't really fly at the same intensity as more 'operational' air arms. I remember a statistic years back in relation to the Alouettes. According to Aerospatiale over the time they were in service the Air Corps should have lost 20 helicopters. In fact they only ever had eight and only lost one in a non fatal accident. On the face of it, that's good and reflects well on the Air Corps safety culture. In reality it's more to do with the fact that there wasn't much in the way of real military operations. The riskiest part was SAR and that was kept to day VFR close to the coast.

It's the same with the rest of the Air Corps. They're rarely deployed away from Baldonnel and never get sent abroad or operate out of austere environments.

As for recent accidents, there are very few CFIT. The PC9 was clearly CFIT. The Dauphin years ago was CFIT but there were other factors. The most recent Cessna crash wasn't CFIT. It was an example of a young pilot showing off for his buddies. History is littered with examples of that kind of accident. Two of Marchetti accidents involved cadets mishandling their aircraft and spinning in fatally, probably unauthorised aerobatics. Another Marchetti crash involved a cadet changing fuel tanks improperly during a simulated engine failure which rapidly turned into a real engine failure. There were others too but the last real CFIT was back in the early fifties when a Seafire hit Corrig Mountain in Wicklow.

So it isn't a big factor. I think their safety record stands up well.

I think all of the listed accidents were in fact "Controlled Flight into Terrain",

My recollection is that the only recent and non-fatal(thankfully) accident that was not CFIT was the Gazelle that had an engine failure, there are also a number of very close calls(C250) which would comfortably fall into the CFIT category..

And you are right the level of operations and tempo of ops in Baldonnel is nothing close to a real military operator and therefore it is very difficult to judge, however the number of CFIT incidents and accidents points to a cultural issue IMHO.

Dochealth

Lack of guarantee of publication is problem. We are no longer in an era where we can assume State bodies will do the right thing.

The flight pattern observed before impact is a source of concern. We need to know if this was emblematic of a culture in AC or a "one- off" event.

This aspect can only be moved forward by full publication plus/minus further inquiry depending on detail of AAIB findings.

xflyer

I have to fault your definition of CFIT, the first word is 'controlled'. Essentially the pilot is unaware there's a problem until it's too late. The classic scenario is exactly what happened to 265. Most often it means an aircraft hitting unexpected high ground. Another variation is to hit the ground during a low visibility approach. The crash that killed the Polish President was exactly that.

The others mentioned were loss of control. The pilots concerned lost control and crashed. That's not CFIT. They would have been very aware of what was happening to them for the final few seconds.

Klunk001

I don't know.The attrition rate on crews and airframes given their size and flight hours flown could be classed as high in a peacetime environment I suppose. Previous IAC accident reports have not been made public ( not including Tramore) for whatever reason, that can't be a good thing in my opinion.

Excluding the Gazelle incident, mechanical error does not seem to have played a part in some of the accidents talked about here. The then minister for defence asked that the AAIU assist the IAC in investigating the pc9 accident, why?. According to the papers the family of one crew member want the report published ASAP so others can learn from it.

As some have said, AAIU reports make recommendation, they are not there to aportion blame.

BantryRebel

xflyer wrote: »

I have to fault your definition of CFIT, the first word is 'controlled'. Essentially the pilot is unaware there's a problem until it's too late. The classic scenario is exactly what happened to 265. Most often it means an aircraft hitting unexpected high ground. Another variation is to hit the ground during a low visibility approach. The crash that killed the Polish President was exactly that.

The others mentioned were loss of control. The pilots concerned lost control and crashed. That's not CFIT. They would have been very aware of what was happening to them for the final few seconds.

Just wondering how you know this, is there an interim report that sates that and is it available online?