A “CASCADE of errors” partly contributed to the death of a gliding enthusiast at Carrick airfield in 2013, an inquest has heard.
They ranged from radio communications to visibility and application of safety procedures, counsel assisting the coroner Peter Aitken said on Monday.
The inquest before Coroner Mary Jerram is examining the cause and manner of 50-year-old Mosman man Andrew John Ahern’s death on April 27, 2013 at Carrick airfield.
He and his instructor were sitting in a Blanik L13, poised 30 metres above the air on a winch when a landing Nimbus craft clipped its wing. The Blanik crashed to the ground, killing Mr Ahern.
His level two instructor, 70- year-old Tallong man Lindsay Gamble, sustained a broken leg.
The Nimbus pilot, 72-year-old Canberra man and level three instructor, Peter Jolley escaped injury.
“Stop, stop, stop,” was the final transmission before the crash, the inquest was told.
Magistrate Jerram said the inquest was not designed to “point the finger of blame.” Nor was it a criminal proceeding.
“We are here to find out why it happened and whether there is anything that can be done to prevent it happening again,” she said.
Mr Ahern’s widow, general practitioner Dr Catherine Brassill and daughters Felicity, 18 and Elizabeth 22 sat in the gallery.
In his opening remarks, Mr Aitken pointed to Gliding Federation of Australia Drew McKinnie’s investigation.
“As indicated in evidence given by Mr McKinnie: ‘In this case it was a complex cascade of errors, latent conditions and failed defences that combined in an accident causation chain with fatal results,’” he said.
Mr Aitken said the inquest would explore whether it was an avoidable occurrence.
It would consider the accuracy and appropriateness of communication procedures, the checking of radio and safety equipment, training of club members in safety, the visual impact of a line of pine trees near the landing strip and measures adopted by the Southern Tablelands Gliding Club since Mr Ahern’s death.
On that day, Mr Ahern, an experienced glider, had been undertaking a re-accreditation flight because he hadn’t flown in more than 90 days, Mr McKinnie told the Post in May 2013.
The inquest heard that the Blanik had “physical restrictions” that made it difficult for the pilot to see what was happening behind.
As such, crew were partly relying on radio communications and observations by ground operators at the wing, in a communications van and at the winch.
Mr Aitken said Mr Jolley, in the Nimbus, was aware the Blanik was ready to launch. In his statement Mr Jolley said he negotiated two 90 degree turns as he came in to land and made two radio calls to make ground crew aware.
“It is common ground that those radio calls were not heard by anyone on the ground (but) there was potential for them to be heard at three points,” Mr Aitken said.
Mr Jolley had soared to 2000 feet and when coming in to land, flew some 50 metres above a row of pine trees. In his statement he said he could see the Blanik but expected it to launch at some point. It was still on the launch when he lost sight of it.
“It seems nobody was paying attention to the Blanik,” Mr Aitken said.
Some 1.7km away, Gliding Club president John Wilkinson was operating the winch with member Colin Veal.
Mr Wilkinson told the inquest that on a cloudy day, it was almost impossible to see a white glider like the Blanik against the white background of clouds. He said it was everyone’s responsibility to ensure safe operation; radio communication was not the only means and a ‘see and avoid’ procedure was also in place.
--- communications breakdown But radio communication came under intense scrutiny. Mr Aitken said the Blanik was required to radio to a communication van, colloquially known as the pie cart, confirming it was ready for departure.
In his statement, Mr Gamble said he heard this confirmation back from the van. In contrast, Mr Jolley said he didn’t hear it.
Mr Aitken said the inquest would hear from the Gliding Federation as to why confirmation of the launch call was not mandated.
Complicating matters was that Mr Jolley was tuned to a frequency that only allowed communication between gliders. The Blanik, on the other hand could have been tuned to a broader Communication Traffic Advisory Frequency, designed to alert craft of other potentially conflicting aircraft extending to a 10 nautical mile radius of Goulburn airport.
“So it’s an issue of who was listening to what and whether others could also hear other frequencies,” Mr Aitken said.
The inquest later heard from Mr Wilkinson that while up at the winch, he had turned the communication radio down due to excessive interference. He had only turned it back up “about one minute” before the crash occurred and so had not heard any transmissions during that time.
While he had been doing this, Mr Veal had gone to move sheep from the airfield.
“Stop, stop, stop,” was the final transmission before the crash.
Mr Wilkinson also conceded during evidence that the Club was using a single runway for takeoff and landing that day.
This was despite changes to procedures “around 2010/11” requiring separate runways. It was not implemented due to any particular incident but was considered prudent in terms of managing risk, he said.
But on May 27 the club reverted to one runway due to the brief time they needed it for two gliders, the length of grass on an adjacent runway and the delay in setting up the Blanik for the day.
Mr Wilkinson told Mr Aitken it was not the first time since 2010 that a single runway for takeoffs and landings had been used.