Analysis – Monarch Crash Coroner’s Report

In a similar vein, the Coroner found the Monarch Chief Pilot, Brad Wilson, “deserving of the highest degree of criticism and censure” in permitting the Piper Navajo to be flown in its deficient equipment state.

The then CAA was found to have gone out of its way to protect charter operators from regulations, placing the commercial interests of its ‘customers’ above the safety of the public. Likewise, the NSW Air Transport Council was found to have ignored a mountain of evidence that Monarch’s management was running a potentially dangerous operation.

On the question of ‘skill fatigue’, the Bureau of Air Safety Investigation was quoted in the Coroner’s report as stating that it is a deterioration in performance caused by work that demands persistent concentration and a high degree of skill.

From all the evidence it would appear that the outcome was inevitable before the aircraft even took off; a seriously deficient aircraft being operated by an airline in trouble, coupled with a pilot under extreme pressure to complete a flight in marginal weather conditions.

As previously reported (refer p25 Sept 94 AA), weather conditions at the time of the accident were marginal and possibly below the minima for the type of approach being flown. There were apparently problems with the radio-activated runway lighting and three NDB non-precision approaches were required before a circling approach for a visual landing could be commenced. BASI also established that the undercarriage was not fully extended at the time of impact, which might indicate that an undercarriage malfunction problem was also being experienced.

There is no doubt that Wayne Gorham would have been under considerable pressure to undertake the flight and, equally importantly, to complete it successfully in commercial terms, i.e., to deliver the customers to their intended destination. His job could have been on the line if he had not been prepared to fly the aircraft even though it had equipment deficiencies which rendered it marginally safe for the flight in question. Hanging over his head may have been the prospect of another pilot being called in to take his place, with the inevitable consequence of the termination of his employment.

As best can be established, the co-pilot, Brynley David Baker, was carried as a crew member to merely act as a ‘human’ autopilot. This was required by the Permissible Unserviceability document (PUS) issued by the then CAA District Airworthiness Manager, and it is assumed that Baker played no part in the decision-making processes associated with conducting the flight.

As to the question of ‘skill fatigue’, it would be reasonable to assume that it did not set in until some point during the series of NDB approaches. During the flight to Young, Wayne Gorham would have had to develop a completely new instrument scan to take in the directional gyro in the co-pilot’s instrument panel since the gyro in his panel was missing. Instrument flying is a skill that can only be developed through thorough training and constant practice. (The old saying that there is no such thing as a “weekend” instrument rating holds very true.) Developing a ‘scan’ to take in the six instruments of the standard instrument panel takes time to master, and for the scan pattern to be imprinted on the brain. (All instruments should be covered in a two-second cycle referring back to the master instrument, the artificial horizon, throughout the ‘scan’.)

To have one of the instruments taken out of the established scan and placed half a cockpit width away would result in the need to break the established pattern and develop a new one. This would be less of a problem in cruising flight, but once an approach was commenced, the brain would have been heavily taxed to continue to reject the old pattern and to accept the new, at the same time coping with an instrument letdown in what were marginal conditions.

Man is not a machine. Wayne Gorham’s stress levels would have been building up through the difficulties experienced in activating the runway lighting, possible undercarriage problems, and the memory of two previous missed approaches, to the point where his mental overload or “skill fatigue” would have been extremely high.

He then had to contend with a circling approach, relying on the directional gyro in the co-pilot’s instrument panel for heading information. Again, the disruption to the established scan pattern would have increased his workload as he endeavoured to determine how far the aircraft had proceeded around the arc of the circling approach, i.e., what his heading was in relation to the runway alignment.

His difficulties would also have been exacerbated by having to look across the cockpit to the runway from the left-hand seat on a right-hand base. It was apparently a very dark night with low cloud; the only visual reference being the runway, assuming that he could see it. Again, there is an old truism that you are either on instruments or you are flying by visual reference; to attempt both at the same time has proved fatal many times in the past.

The fact that three approaches were made would indicate a determination to land at Young to complete the flight successfully in commercial terms, or that the prospect of yet a further series of approaches at a diversion airfield, with the difficulties already experienced with a seriously deficient aircraft, was too much to contemplate.

Although precisely what happened will never be known, it is possible that the pilot encountered low scud cloud on the circling approach and lost visual reference. By this time he was most likely too fatigued to make a rational decision to abort the approach, and went below the published minimum circling altitude, striking the trees on high ground with the fatal result.

Comment

Taking all the above into account, the question needs to be asked: why did the pilot continue the flight when diversion procedures are clearly laid down to prevent just such an occurrence? Was it because of commercial pressures, or had the pilot passed the point of rational decision-making due to skill fatigue?

From all the evidence it would appear that the outcome was inevitable before the aircraft even took off: a seriously deficient aircraft being operated by an airline in trouble, coupled with a pilot under extreme pressure to complete a flight in marginal weather conditions.

The next obvious question to be asked is, how to prevent a re-occurrence?

It would be too easy to say that the pilot should have refused to undertake the flight because of the equipment deficiencies. Not only could he have lost his job as an immediate consequence, but he could have been contributing to the demise of the airline with the loss of his job in the longer term.

Reporting the airline anonymously through the BASI Confidential Aviation Incident Reporting (CAIRS) system would have been an option, but again there is the question of whether this would have caused the demise of the airline and the loss of his job.

The answer can only really lie in preventing the rot in the first instance, and that will only be achieved through an efficient, effective and timely oversight of operators by CASA.

However, the other side of the coin is that too hasty, public condemnation of an operator would lead to the rapid demise of the organisation concerned (refer p30 March 96 AA, comment on the Morris Report). Public confidence in matters of aviation safety is very fragile in this country vis-a-vis our apparent acceptance of our appalling road accident record.

Millions of dollars are spent on aircraft accident inquiries. If pro-rata sums were spent on road accident inquiries, the country would be truly bankrupt!

Aircraft accident inquiries rapidly degenerate into political point-scoring exercises with the lawyers the only true winners. Perhaps a standing independent accident inquiry commission devoid of all the extraneous trappings such as we have seen with the Monarch and multi-million dollar Seaview inquiries might be the answer. The money saved could then be put to better use in overseeing airline/charter operators and preventing the accident in the first instance.