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| CayleysCoachman
January 30, 2025, 22:14:00 GMT permalink Post: 11817697 |
Listening to the ATC transcript on YouTube, one can clearly hear ATC receive a conflict warning as the CRJ and the Blackhawk get close. Why on earth didn't ATC immediately instruct the helo simply to "PAT25 turn left hdg xxx IMMEDIATELY, I say again ..." , instead he again asked for verification that PAT 25 had the CRJ in sight?
In such close distance, on a collision course, there is no place for a question, but an INSTRUCTION, as ATC is the only one with a clear overview of the situation. Not trying to put blame here, but the controller needs to step up once he gets a conflict warning and act, and ask questions later. RIP to all involved, a truly sad and avoidable event. Subjects
ATC
Blackhawk (H-60)
CRJ
PAT25
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| CayleysCoachman
January 30, 2025, 22:26:00 GMT permalink Post: 11817707 |
Subjects
IFR
See and Avoid
VFR
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| CayleysCoachman
February 01, 2025, 21:50:00 GMT permalink Post: 11819327 |
From experience, I’m pretty convinced the Army crew never saw the CRJ and vice versa. IF they did, there was no time t9 take evasive action to miss—it’s just too late. In my mid-air,the investigation showed that, once visual, any action would only change in the impact angles.
However, there is a case where, due to visual illusions, the crew took “evasive” actions that created a mid-air collision. EAL and TWA over the Carmel VOR in 1965. The cloud deck was angled in a fashion that created the illusion they were head-on co-altitude, when in fact, they were separated. EAL FO pulled up to avoid and collided. https://en.wikisource.org/wiki/Aviat...-air_collision https://assets.publishing.service.go...-KAY_02-09.pdf Page 61 lays out the possibility that in manoeuvring to avoid a perceived risk of collision, a pilot may have unwittingly flown into a different collision. Subjects
CRJ
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| CayleysCoachman
February 01, 2025, 22:34:00 GMT permalink Post: 11819350 |
That’s an awfully cluttered display, chock-a-block with information with no salience whatsoever. For many years, I flew a lovely large piston twin, being passed down almost from one owner to the next, with the aircraft, until its last owner installed acres of Garmin glass. I could no longer perceive the propeller RPM with sufficient granularity; the fuel flows were obscured, the whole place became like Blackpool illuminations, and, as I was fundamentally only flying it for my own pleasure, I stepped back.
Urgent information needs salience in displays and suitable attention-getters, but in that regard, proximate traffic near an airport could be given greater prominence, then to be lost in learned noise. TCAS is not the answer to this collision. I’m increasingly reminded of the term, ‘defensive controlling’. Yes, you expect to have vertical separation if the climber stops at its cleared level, but why not give it a five degree heading change, not to achieve any kind of separation, but just to make sure they don’t hit if it busts…. The transfer of responsibility to the helo crew here was entirely legitimate, but also created the single point of failure which led to a collision, and that was foreseeable. Subjects
Separation (ALL)
TCAS (All)
Vertical Separation
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| CayleysCoachman
February 21, 2025, 21:35:00 GMT permalink Post: 11833266 |
Those fiddling with decent angle, flight path clearance, routing, etc are only considering the symptoms of this accident; not the illness which created the situation, and which could generate other, similar situations not effected by minor interventions.
Beware of fixing the last accident, whereas the underlying issues remain, festering until the next opportunity. Subjects
ICAO
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| CayleysCoachman
February 22, 2025, 09:00:00 GMT permalink Post: 11833498 |
#
1194 Caley,
"… and yet that is precisely how ICAO stipulates that accident investigation should work. The consequent focus on such things as ‘proximate cause’ and the inherent unwillingness to deal with underlying aetiology work against holistic approaches and generate exactly the outcomes you warn against. " In part yes, I agree. However, as you might know, ICAO does not 'stipulate', it provides recommendations and standards of practice (SARPS), e.g. Annex 13, on which nations can base their investigation and reporting. As such it is the interpretation of by individual nations and their investigators which direct investigation, findings, and recommendations. Some nations interpret SARPS better than others. There is an interesting example (amongst many others) of wider investigation and reporting in the Fukushima accident report: Pprune Safety Forum Fukushima Nuclear Accident Investigation Reforming the regulators The Commission has concluded that the safety … cannot be assured unless the regulators go through an essential transformation process. The entire organization needs to be transformed, not as a formality but in a substantial way. … regulators need to shed the insular attitude of ignoring international safety standards and transform themselves into a globally trusted entity . P.S. Re the investigation above, also noting 'Cosmetic Solutions'; if the findings from this DCA investigation warrant it, would the NTSB conclude 'This was a manmade accident, made in the USA' .ii Regarding Fukushima, the problem lies not with regulators, but with regulation and its evil twin, compliance. And on your last line, I might add, 'by politics'. The process of sharing draft reports with interested parties is harmful enough to the investigative process, as we have seen with crystal clarity over the Clutha case for example, but is even more damaging in its influence to the jobbing investigator sitting at a word processor, thinking not only of that process, but all the petty politics which are exercised by managers in SIAs. Sometimes the investigator feels charged with writing a benign account of a series of improbable, unfortunate, and unforeseeable coincidences, which aligned with previously unknown holes in otherwise-solid cheese, despite being fully aware that there is much more to it than that. Subjects
DCA
Findings
ICAO
NTSB
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