MR ERIKSEN CALLS
+BARRY ARTHUR SARGEANT AFFIRMED
RETIRED
+EXAMINATION BY MR ERIKSEN
Q. You described your present occupation as retired, however I think as at May 2001 you were still employed by ATSB.
A. That’s correct.
Q. In your employment with ATSB, can you just tell his Honour what it was, or perhaps if we go back to the beginning. When you were employed by the ATSB, at the time of your retirement, you were a deputy director.
A. Deputy Director of Air Safety Investigation.
Q. And if we can then go back to the beginning and you explain to his Honour what your qualifications are and your expertise and how you came to achieve that status in the ATSB.
A. Yes, if I may just refer to my list.
Q. You have some notes.
A. Yes.
Q. You ask his Honour’s permission to refer to those.
A. Yes.
PERMISSION TO REFER TO NOTES, COUNSEL NOT OBJECTING
A. I hold an Australian Air Transport pilot’s licence. Total flying experience in excess of 9,000 hours. I completed a basic accident investigation course which was run by the Bureau of Air Safety Investigation in Canberra in 1983. I completed an advanced accident investigation course again conducted by the bureau in 1984, I did a further course in major accident investigation management again run by the bureau in Canberra in 1986. I completed the National Transportation Safety Board Boeing 767, 757 Investigation Course run by the Boeing Commercial Airplane Group in Seattle, US in 1992; completed the crash survival course in Phoenix, Arizona in 1995. I’m a member of the International Society of Air Safety Investigators and I have extensive experience as an air safety investigator.
Q. Approximately how many fatal aircraft accidents have you investigated.
A. It would probably be at least 20.
Q. In addition to that, there would be numerous aircraft incidents which haven’t resulted in fatalities that you have been involved in the investigation.
A. Yes, there have been many many accident investigations and far more incident investigations where there was no injury or damage to persons or aircraft.
Q. In particular I think that you were the chief investigator involved in the Monarch air crash which occurred in NSW in approximately 1993.
A. Yes, in Young in 1993 I was investigator in charge of that accident investigation.
Q. That proceeded before a Coroner in NSW for some months.
A. Yes, approximately six months.
Q. You gave evidence in that matter.
A. I did.
Q. You were assisted I think by Mr McIlwaine SC.
A. On that occasion, that’s correct.
Q. You have, during the course of your duties with the ATSB, worked with both Mr Cavenagh the investigator who took over -
A. Yes, I have.
Q. After you retired.
A. Yes.
Q. And you have also worked with all the personnel associated with the Canberra ATSB operation.
A. Yes.
Q. As well as Sydney.
A. Yes.
Q. And that includes Dr Romeyn the metallurgist materials expert - an engineering expert associated with the ATSB.
A. Yes, I have.
Q. We have heard from Mr Cavenagh that the investigator in charge of compiling reports or reports on investigations into fatal aircraft accidents has a team available to him and he delegates or consults with various members of that team and pulls together information and compiles it into a report.
A. That’s the case, the investigator in charge is primarily the manager of the investigation.
Q. Looking at C73D, that was a document that was compiled under your supervision and direction.
A. Yes.
Q. Can you tell his Honour, in general terms what other members of either the ATSB or any outside experts were used to gather information to assist you with the compiling of that report.
A. I relied on advice from all the members of the investigation team and they, in turn, would have probably got - well they would have also received advice or information from members external to the ATSB.
Q. Can you tell his Honour the circumstances whereby draft report is released to interested parties and what the reason for that is, releasing the report in draft form.
A. Yes, I prepared a draft final report and that was then sent out, in accordance with the ATSB policy to persons or people identified as interested parties to the investigation such as relatives of the deceased, the aircraft manufacturer, the aircraft owner and operator and so on, and that was sent out and they are normally given about 21 days to a month depending on the circumstances, to provide a response and if they can give evidence that would substantiate the ATSB changing elements of the report, then that will be taken into account, the report will be amended to reflect those changes before the final report is released.
Q. During the course of your investigation were you in reasonably constant contact with the interested parties, that is relatives of the deceased and -
A. During the investigation I did have contact from time to time with various parties, that’s correct.
Q. That’s part of your job as the investigator in charge to deal with people who have concerns and interest in, a valid interest, in the investigative process.
A. That’s correct, yes. I would normally provide my direct contact number to interested parties. If they wanted to discuss the matter with me they were at liberty to do that.
Q. Now, at what stage did you cease to have any association with the investigation, I think you told us you prepared a draft report whilst you were employed by the ATSB, was circulated to interested parties, were you there when the responses came in.
A. I was there when some of the responses were arriving. I briefly looked at them. This was probably around about the beginning of May. I finished my time at the ATSB on 23 May and the last few weeks I was doing a number of things, so I didn’t really get involved with responding to the interested parties.
Q. The circumstances in which you departed the ATSB, that was all in accordance with normal business operations and you departed on happy terms with everyone.
A. Very much so, it was negotiated with the executive director; that was done some six months before I retired. It suited the ATSB, certainly suited me. No, we departed on very good terms.
Q. Indeed you still have very good relationships with both the executive director and all other members of the ATSB.
A. Yes, there’s absolutely no question about that.
Q. You were contacted by Mr Kernahan the solicitor associated with this inquiry and asked to consider the final report, that is C97 and provide any comments that you thought were appropriate. In general terms, is that right.
A. Yes, that’s right. I originally had been contacted by Sergeant Goodwin and given an indication I may be required to appear. I was subsequently contacted by Mr Kernahan, as you’ve indicated.
Q. In accordance with that request did you prepare a summary of your opinions which you signed and dated 12 November 2002.
A. Yes, I did. I should point out Mr Kernahan didn’t request me to do that. I was just taking notes as I read through the reports and I felt it was probably more effective if I provided an additional statement, so I did so.
Q. Looking at the statement now produced to you, which contains a letter to which the statement is attached, is that both the letter and the statement that you prepared in accordance with what you thought was relevant material to assist the Coroner in this inquiry.
A. Yes, it’s a copy of that document and it was designed to assist his Honour’s understanding of the modes of engine failure and the sequence in which they occurred. I basically stayed with that in mind.
MR ERIKSEN: I had given consideration to the provisions and, in particular, that as I understand it, any investigator, if he gives evidence in a court it may well be - I’ve discussed this with Mr McIlwaine, and it’s difficult to identify exactly what areas are which come within the provision of the Air Navigation Act, but I’m just wondering whether it’s prudent for your Honour to make an order under s.19(h) (d) (8) which just says: ‘If an appropriate court is satisfied that the public interest to the disclosure ... the court must order such disclosure.’
I'm just wondering whether an order to be made that this witness be allowed to disclose such information as he deems necessary to inform.
MR MCILWAINE: I don't wish tom ace any submission as to whether or not you should make the order, of course, but, you will have to satisfy yourself that the public interest in the disclosure or production of air safety records 'outweighs the adverse domestic', et cetera. I have nothing to say about that.
Also you will have to make an order in accordance with sub-s. (9) which restricts access to air safety records to persons or persons constituting the court, parties to the proceedings and their legal representatives, so I would assume you would probably restrict it to those people who have been granted leave to appear and would include the Mr Broughams in that as well. They are not strictly represented here, I think they would fall within the group of people, but it is necessary to give Mr Sargeant the protection he needs under the Act if such an order is made.
CORONER: To what extent - I have a letter from Mr Kernahan, I have a document headed 'additional statement'. I have an initial document called a 'statement', what are they?
MR ERIKSEN: The only one I'm interested in is the one dated 12 November and an additional statement to assist the Coroner of some 15 pages dated 12 November.
CORONER: This other statement is dated 6 November.
MR ERIKSEN: As I understand it, the one dated the 6th was the draft statement and the one that you adopt is the 12th.
A. I believe it was 6 November of 2000; that was designed to give your Honour a bit of a heads up on where we were going with the investigation at that particular time.
CORONER: This is November this year.
MR ERIKSEN: November this year, it is really only the one of the 12th we're concerned with.
CORONER: To what extent can that be considered an air safety record?
MR MCILWAINE: I don't think the statement itself would be considered an air safety record it's based upon material Mr Sargeant would have learned.
CORONER: From records.
MR MCILWAINE: Yes. The Act speaks of 'a person who is or has been an air safety officer must not directly or indirectly', it's the 'indirectly' - the extent to which we need you to exercise your discretion to identify what air safety records Mr Sargeant has taken in account, is a difficult question and it may be, as Mr Sargeant's going through is evidence, he might indicate - he has a good working knowledge of what are air safety records and what are not, when he's relying on air safety records otherwise he commits an offence, that's what we're trying to avoid.
CORONER: This statement, as you say, is not an air safety record in itself.
MR MCILWAINE: No, indirectly it contains information from air safety records, indirectly.
CORONER: Do you say I should restrict access to it on that basis under sub-s.(9) or merely that if an air safety record is called for and produced that I should restrict access to that?
MR MCILWAINE: No, I think reading that strictly because of the word 'indirectly' you would have to restrict access to that statement as well, indirectly it is disclosing air safety records. I'm not trying to confine it to any group of people, I simply suggested the group, being the convenient group, but it's really for Mr Sargeant's protection.
CORONER: What about the evidence Mr Sargeant gives that's not covered by the subsection presumably.
MR MCILWAINE: Yes, it is, because the prohibition is against him disclosing to any person or to a court the whole or any part, or producing to any person, or to a court, so the production of course is the document, the disclosure is the oral evidence, buy your order can permit him to do that, provided you're satisfied and there's no reason that I would put to you why you shouldn't make the order.
CORONER: I actually don't have a copy of the Act here do you have a copy of that?
COPY OF ACT HANDED TO HIS HONOUR
MR MCILWAINE: 19 (h) (c) which starts (1) various things:
'A person who is or has been an air safety officer must not directly or indirectly disclose to any person' - there's a penalty for that, we don't have to worry about (2) to (6), I can tell your Honour this court is an appropriate court. So it's then you move on to sub-s. (8):
'If an appropriate court is satisfied that the public interest ... must order such disclosure.'
CONTINUED
C0RONER: That's clear enough.
MR MCILWAINE: And then it sets out the restrictions on access but again that's a matter entirely for your discretion.
CORONER: That's my question. It says 'makes an order and restricts access to the air safety record itself'. I mean once Mr Sargeant's evidence is on the transcript, do you say that I should restrict access to the transcript on that basis?
MR MCILWAINE: No, 'unless the court is satisfied that such an order would not be of a court performing its functions'. The short point is you have to make the order to give him the protection.
CORONER: I will certainly give the order for disclosure under sub-s. (8) there is no problem there. Do you say I should make an order under sub-s. (9) restricting access to Mr Sargeant's statement?
MR MCILWAINE: No, I think you should make an order under sub-s. (9) not restricting it.
CORONER: I follow you. I think I misunderstood you earlier. I thought you were arguing to the contrary on that.
MR MCILWAINE: No.
CORONER: I will make an order pursuant to s.19HC sub-s. (8) of the Air Navigation Act that Mr Sargeant disclose the contents of an air safety record as defined in the Act to the extent that is already contained in his statement dated 12 November, 2002, being satisfied that the public interest in this matter of the record outweighs the adverse domestic and international impact such disclosure or production may have on the investigation to which the record relates, or to future investigations, thee having not been put anything before me that would indicate that any such adverse effect will occur. And of course I invite counsel if, at any stage during the evidence that further disclosure of air safety records calls for a further exercise of this discretion, to draw that to my attention and I will make such orders as are required.
I make a further order pursuant to sub-s.(19) of s.19HC that I am satisfied that it would not be in the interests of justice nor would it be desirable in the interests of my performing my functions in the inquest to make an order restricting access to the statement and Mr Sargeant's evidence, so I accordingly will not make any such order restricting access.
EXHIBIT #C210 MR SARGEANT'S LETTER OF 12/1/2002 AND STATEMENT OF THE SAME DATE CONSISTING OF 15 PAGES TENDERED BY MR ERIKSEN. ADMITTED.
MR ERIKSEN
Q. I think when you first became associated with this inquiry you had the following facts as least available to you: that a twin- engine aircraft en route from Adelaide to Whyalla had ditched approximately 12 to 15 nautical miles from Whyalla with double engine failure shortly prior to ditching.
A. Yes. That was about all I knew at that stage.
Q. And being a pilot, and a mature aircraft accident investigator, did initially some scenarios present to you which you thought were worthy of first considering.
A. Yes. There was the possibility of a double engine failure, some sort of mechanical failure which I tended to rule out, more likely due to fuel exhaustion and this was somewhat reinforced shortly after when it was reported on the transcript of the communications that the pilot had reported both engines had stopped or he lost both engines and I at that stage and the rest of the team felt it was probably fuel exhaustion.
Q. And is that because the advent of a double engine failure, especially when the double engine failure or the engines fail for completely different reasons, is a very unusual event in aviation history.
A. Yes. At that stage we didn't now what had really gone on and we can only surmise that he lost both engines. That's all we knew and to have two mechanical failures in the one flight it's - while it's not impossible its extremely unlikely.
Q. Indeed, we have heard that from almost every witness. When you had the aircraft in your custody and control, you authorised investigations and received information regarding the left engine and the right engine, so can you tell his Honour at that stage - your thoughts were in their embryonic stage, did you have a tentative opinion on what might have occurred.
A. Yes, I must say I and the rest of the team were very surprised to find mechanical damage to both engines and the mechanical damage was different, and it would appear that the right engine had suffered some sort of over-temperature condition, the left engine had some sort of catastrophic mechanical failure, and it appeared at that stage as though the left engine may have failed first, and for some reason or other the pilot may have exceeded the temperature limits on the right engine and it resulted in over-temperature damage to that engine and subsequent stoppage. That's what it then appeared to be.
Q. However, as a trained accident investigator into aircraft accidents, you had to factor in all known criteria and facts and did you then have available to you radar evidence which indicated the groundspeed, altitude and heading of the aircraft.
A. Yes. Once I started to analyse the radar data with the assistance of appropriate specialists, it became apparent to us that there had been some gradual loss of performance in cruise of this aircraft, and things that had happened after the aircraft had started to descend; loss of performance was not of a magnitude that would indicate that one engine had failed completely, it appeared that the speed of the aircraft was more than what could have been achieved on one engine, so therefore there had been some degrading of performance of probably one of the engines which would not be in line with the damage which we had seen in the left engine which appeared to have just completely stopped very suddenly. So it therefore seemed to indicate that something had been going on with the right engine and we progressed from that.
Q. So if I can summarise it, that once you had available to you the material from the radar tracings of the flight, you came to the conclusion that it was far more sophisticated than the loss of the left and inappropriate pilot action in respect of the use of the right engine.
A. It certainly appeared that way at that stage.
Q. So you were then faced with a rather, if I could put it, sophisticated inquiry whereby you had to sift out the facts and try and make conclusions or judgements which fitted the known facts.
A. Yes. It needed careful gathering of the evidence and analysis of that evidence to determine just what was the most likely reason this accident happened the way it did.
Q. As a matter of methodology, in C97 the executive summary on p.(ii) there is just a preamble to the report which states, fourth paragraph, 'Under the Air Navigation Act, it is not the object of an investigation to determine blame or liability'. You agree with.
A. I do.
Q. You are not there to sort out any civil disputes between interested parties.
A. No.
Q. And the preamble goes on to say 'However, it should be recognised that an investigation report must include factual material of sufficient weight to support the analysis and the conclusion reached'. As a matter of principle, do you agree with that.
A. I certainly do.
Q. And that was the principle which governed your investigations up until the time you left the ATSB.
A. Yes, it was.
Q. Can you tell his Honour what - and refer to either the draft report C73D or your summary of where you refer to the draft report and the final report C210 if you want to - did you have advice tendered to you in respect to the manner in which the crankshaft on the left engine failed.
A. Yes. That was provided to me by a specialist in metallurgy employed by the Bureau.
Q. Was that Dr Romeyn.
A. It was.
Q. Did you have an opportunity of conferring with a Dr Kym Yoon - I don't know whether he's known as that or just Dr Kym. In any event he was a metallurgist associated with Textron Lycoming.
A. I believe I met him briefly. I don't believe I conferred with him.
Q. You are unable to say whether you ever saw him examining any of the damaged parts of the aircraft in particular the left-hand crankshaft.
A. It was my understanding that he visited our facility in Canberra and he did examine the crankshaft. To what extent, I just don't know.
Q. You don't know whether that was microscopic examination or just visual examination.
A. No, I don't know.
Q. Do you know a Mr Blythe.
A. Yes, I do.
Q. And did you have any discussions with him regarding any of the metallurgy associated with the left-hand crankshaft of MZK.
A. Look, I probably did at various times, not to any great depth, exactly what was said and when and how many times, I can't recall.
Q. In any event, I think that your draft report had attached to it some written advice that you had received from Dr Romeyn.
A. Yes. I eventually received a report from Dr Romeyn.
Q. I think that unfortunately about this time or during the course of the investigation Dr Romeyn unfortunately suffered a very severe fracture of his foot.
A. Yes, he did, and that delayed proceedings somewhat.
Q. I think it's para.3, the annexure that was attached to the draft report containing Dr Romeyn's views are at the back of the report.
A. Yes, attachment A.
Q. Its attachment A and is headed 'Executive Summary' just after p.63. In any event, the report speaks for itself, that is attachment A, that attachment was prepared by Dr Romeyn and incorporated in the report.
A. Exactly.
Q. Would I be correct in saying that you would defer to Dr Romeyn in respect of matters involving metallurgy and engineering and when I say engineering, chemical engineering and mechanical engineering.
A. I would certainly defer to his qualifications and material in his analysis, yes.
Q. In respect to the commencement of the fatigue crack in respect of the left crankshaft, at para.3 of the attachment that's where Dr Romeyn discussions the mechanism involved or in his opinion associated with the commencement and propagation of the fracture of the crankshaft which subsequently ended up in two pieces.
A. Yes.
Q. At that stage, there is no mention that I can find in Dr Romeyn's final analysis of any reference to lead oxybromides.
A. No. I had no knowledge of lead oxybromide deposits until I read the final report of the ATSB. At that stage they were referred to as 'leaded deposits'.
Q. And prior to reading the final report C97, is the term 'lead oxybromide' a term that you had encountered in your many years as an aircraft accident investigator or as a pilot.
A. No, it wasn't, but then I'm not an expert in that either.
Q. You had been associated for many years with a number of accidents.
A. Yes, that's true.
Q. As I understand it, Dr Romeyn presents the hypothesis in para.No.3 that 'The crankshaft was subjected to significant loads both bending and torsional and alternating stresses.
A. Yes.
Q. On the bottom or the last paragraph Dr Romeyn goes on to state 'In the case of the failure of the left engine crankshaft, the characteristics of the fatigue fracture (initiation between the crankarms and crack growth on a plane approximately transverse to the journal) indicates that crack initiation growth occurred under, predominantly bending loads'.
A. Yes.
Q. He goes on to say that 'Initiation at the top dead centre indicated an abnormality - advanced timing or the presence of a stress concentrator. Features that cause the magnitude of stresses to be increased in localised regions sufficiently increase the likelihood of fatigue cracking'.
A. Yes.
CONTINUED
Q. Over the page he goes on to state that 'A feature of the surface hardening created by the nitriding process is a loss of the ability to perform plastically and a propensity to crack as high stresses are developed in the surface of a component'.
A. Yes.
Q. And then later on, when he deals with the connecting rod big-end bearing failure he states at para.3, 'There was evidence however that bearing insert movement had occurred during operation'.
A. Yes.
Q. He then goes on to say 'The loss of the inserts from No. 6 journal bearing is consistent with the progressive reduction of insert retention forces'.
A. Yes.
Q. And you discussed with him, from time to time, his failure in respect of the left crankshaft.
A. Yes, I spoke with him a number of times about that.
Q. And as understand it, am I correct in saying that it was his view that there was, first of all, a thermal crack which then caused a fatigue crack, and the thermal crack was caused by the loss of bearing shell, or part of the bearing shell which resulted in fillet override at the site of where the crankshaft commenced to crack.
A. Yes, essentially his argument was that the bearing had failed and that in turn had commenced this cracking process of that particular part of the journal
Q. Eventually that propagated through to the extent that the crankshaft ultimately failed.
A. Yes, after some 50 odd flight hours.
Q. In his analysis the commencement of the crack in the crankshaft, and let's say that that's the thermal crack, commenced 50 flights, approximately 50 flights prior to the disastrous flight on 31 May 2000.
A. Yes, I talked to Dr Romeyn about '50 hours' or '50 thermal cycles', he described it as, consistent with a flight, take-off, landing, about 50 hours or so before the final breakage of the crankshaft.
Q. And that the commencement of the thermal crack was in fact the loss of the bearing shell causing the big-end to over-ride on the fillet radius.
A. That's correct.
Q. At that stage you were aware, if you go back to p.20 of the draft report, C73D, that the examination of the oil filter of the left engine had revealed large metal debris particles in the filter.
A. Correct.
Q. You were also aware that some four and a half or five hours prior to the fatal flight that the aircraft had been the subject matter of a 100 hour service.
A. Yes, checks 2 and 3 had been carried out.
Q. And involved in those checks were the examination of the oil filters.
A. Yes, oil filters, strain inspection and oil change.
Q. And there had been no abnormality found especially in respect of metal particles.
A. Yes, I was given advice to that effect.
Q. What I'm putting to you is would you agree with me there seems to be an inconsistency in a hypothesis that says that 50 flights before you have a bearing shell or bearings chopped out, and yet this; between then and the fatal flight you have an examination of the oil filters some four to five hours prior to the fatality, and there is no finding of metal particles in the oil.
A. That's true, and that was something that did concern me.
Q. And, indeed, that was a matter that was the subject matter of discussions between you and Dr Romeyn.
A. Yes, I did speak to Dr Romeyn three or four times before the draft report was sent out, and we spoke about a number of things, but mainly I remember talking to him about the lack of any contamination of the oil or filters. Although I hold no qualifications in metallurgy, I could not quite understand how the big-end bearing could fail without any evidence being shown in the oil or the filters and so on. He assured me that it was possible. I can't recall exactly what his explanation was now, but in the end I accepted that he was right and that was then written into or incorporated in the report.
Q. Would you also have expected, if there had been a loss of bearing in No.6 big-end assembly of the left engine, 50 flights prior to the fatal flight, would you have expected there to have been some loss of oil pressure recorded in the trend monitoring data.
A. Yes, that was one of the number of things that I would have raised with him as well as my concern that the engine could have operated in that condition for that length of time. Again, he was able to assure me that that was possible.
Q. However, I think that, and you point out in your Exhibit C10, that if you go to p.68 of C97, that's the final report, figure 41, that the final report indeed into the defences incorporates what your line of thinking was at the time that you were discussing this matter with Dr Romeyn.
A. Yes, that's right, although I had not seen this diagram until I read the final report, it would summarise my concern that surely there would be some evidence in the oil and filters of some sort of bearing problem or failure early on in the piece, and that was subsequently reinforced with the publication of the final report. I notice it's labelled as a defence or defences, those particular items.
Q. Have you, on any other occasion, investigated an aircraft accident which involved a fractured crankshaft - does one come to mind.
A. One doesn't readily come to mind. I probably have, I just can't.
Q. We have heard evidence in this case that the crankshafts in the Piper Chieftain aircraft are massively over-engineered to cope with excessive stresses and strains and torsional forces. Would you accept that.
A. I would accept that.
Q. So therefore would you agree with me that the fracture of a crankshaft as found in the left-hand engine of MZK presented as a fairly unusual phenomenon as far as you were concerned.
A. As far as I was concerned, yes, that's right, particularly in an engine which had recently been overhauled.
ADJOURNED 11.16A.M.
RESUMING 11.36 A.M.
Q. I have been taking you through the issues regarding a bearing failure 50 flights beforehand, and there being lack of evidence in oil examination and filter examinations during the course of those 50 flights.
A. Yes.
Q. And, indeed, you have particularised that in considerable detail in Exhibit C210 at the beginning. You then make the point that - I'm now at p.4 - you make the point that in the draft report the photograph of the filter, together with the metal debris was, in your opinion, appropriate to point out in the report, and that was deemed to be not of sufficient weight to include in the final report.
A. It would seem that was the case.
Q. In addition to that your draft report said that the oil that remained in the left engine, the small sample that was available, was sent for laboratory analysis. I take it that you can't now remember what that analysis revealed.
A. No, I can't.
Q. But you then went on to say that the oil was of normal viscosity and did not show any signs of coking or blackening associated with overheating.
A. That's correct.
Q. Are you able to say to what degree there has to be overheating before you get the features of coking and blackening, in general terms.
A. In general terms the engine would have to be exposed to excessive heat for some considerable time to see evidence of overheating such as is suggested here. That is coking and/or blackening.
Q. P.5 in your Exhibit C210 you go on to refer to the incidents involving VH-LTW, VH-BNN and VH-ODE when there were failures of big-end housing and/or loss of bearings with phenomena such as low oil flow, and/or increased oil pressures.
A. Yes, the final report stated that these occurrences resulted from No.6 big-end bearing insert failure and I was pointing out that there were, it would appear, the immediate indications of problems which, when you look back to MZK the suggestion that the bearings had failed some 50 hours before the crankshaft failed, it appeared to me there was some inconsistency there.
Q. And that appeared to you to be supported by those examples of what had occurred in those other three aircraft.
A. Yes, I used those examples from the ATSB final report to support that argument.
CORONER: Can you run that past me again? What is point you are making there? I,I'm sorry, I missed it.
MR ERIKSEN: If we go to p.5 you will see that Mr Sargeant says 'The final report that the No.6 big-end insert failure had preceded the initiation of the crack of the associated crankshaft journal which then progressed ultimately to ultimate failure over the next 50 flights or so', that is after he said 'The oil had been checked on a number of occasions' and he has detailed them, and then, as I understand it, Mr Sargeant goes to what is quoted at p.84 of C97 where incidents involving either the failure of big-end assembly, or loss of bearing shell have resulted in the manifestation of either low oil pressures and/or increased oil temperatures, almost - well, in very close proximity to the events occurring, that is the end cap failure, the crankshaft failure or the bearing insert failures, and as I understand it Mr Sargeant says 'Well, if that happens in close proximity to the events occurring then it seems strange that you lose the bearing in MZK 50 flights prior to the fracture of the crankshaft and that the trend monitoring data does not pick up any abnormal oil temperatures, any abnormal low oil pressures, and there is nothing found in the filters when the oil is changed on the occasions that are identified at p.3, bottom of p.3 and 4 when there were various checks and inspections taking place'.
MR ERIKSEN:
Q. Am I right.
A. Yes, that's basically what I'm saying.
Q. So what you are saying is nothing in the trend monitoring data for the 50 flights indicate that it was a loss of a bearing.
A. True.
Q. And there's nothing in the actual investigations carried out by the engineers who were servicing the planes to indicate there were any metal particles.
A. Yes, to all intents and purposes there were no indications whatsoever of the impending failure of the crankshaft yet one could conclude from looking at other evidence from other engines that there should have been early indications of problems.
CONTINUED
Q. I think you're saying this as background to you having some problems in accepting the explanation from Dr Romeyn that the bearing shell failed in No.6 big-end, 50 flights before the fatal flight.
A. Yes, it's my opinion that it didn't happen like that.
Q. Dr Romeyn when you spoke to him, and when you wrote the report annexure A to the draft opinion, was of the opinion that there was a failure of the bearing 50 flights before and that caused the thermal crack which then caused the fatigue crack.
A. Yes, that's right. At that time I accepted what Dr Romeyn was advising me. In hindsight, I now believe that that advice probably wasn't correct.
Q. For you to get the thermal crack at the position where the crack initiated in the crankshaft, you do need some sort of override under the fillet of the big-end assembly.
A. Yes, that would be the case.
Q. And that will not occur unless you have a bearing failure.
A. That's true.
Q. It's most likely to occur if you have a bearing failure.
A. Yes, if that was the mode of failure, or that was the initiator then you would need to have the bearing fail to do that. It can't happen until the bearing has failed.
Q. Going to p.6 here I think you are dealing with issues involved in figure 51 p.82 of the final report. We do have figure 53 and figure 1 up there (INDICATES) it's a bit hard to see from where you are, they are in the final report. If we look at figure 53, that's the one where you pull the page out.
A. Yes.
Q. P.113, if we look at the pink section down the bottom, you see that it's started 'two crankshaft sections remain dogged'.
A. Yes I see that.
Q. Now, I think in general terms you would accept that if the connecting bolts of the end cap to the big-end assembly are intact that you can have a fractured crankshaft or a significant fracture in a crankshaft but it will still be operational.
A. And assuming that the bearing itself is intact, the cap is in place and properly secured, yes, it would clamp the two pieces, it could clamp the two pieces together.
Q. As long as that big-end assembly is clamped, even if there is a certain amount of slop in the connection, if the aircraft is operating at a particular rpm the horsepower appropriate to that rpm operation will be developed by the aircraft.
A. By the engine it should remain the same.
Q. So, just so we understand that, whilst the big-end assembly at No.6 is still around the crankshaft and the crankshaft is still driving the auxiliaries you should get the appropriate power going to the prop.
A. Yes, the piston is being driven through the conrod and developing power to the propeller, yes.
Q. Any scenario, when we look at figure 53, which involves the big-end assembly still being attached to the crankshaft, with there being a slow loss of power, in your opinion cannot be sheeted home to the left engine as long as the big-end-end assembly is still holding.
A. As long as the crankshaft pieces remain dogged, that;s the case, I can't see how there can be any change in the power output.
Q. You concede there may be a lot of damage being done as the power's being produced, especially if the bearings have been chopped out.
A. Yes, it's likely that from the moment the journal cracked that there would be bending and there would be the normal loads you would expect, that in turn would mean that the two pieces would not probably remain exactly in line, so there would be a slight cutting edge, if you like, in one piece, that would start - as far as I'm aware would start to chop out the bearings quite quickly.
Q. But, up until a minute or shortly before the release of the end cap you would expect that engine to produce the rate of power for the revs that it was operating at.
A. Yes, apart from perhaps a gradual reduction in oil pressure the pilot would be more likely unaware there was a problem.
Q. Indeed if one postulates that the bearings were chopped out very quickly, that is, once the crack developed to the extent that one side of the crack was prouder than the other and it chewed the bearings out, you would expect that to occur quite quickly.
A. It would be probably some minutes, I don't know exactly.
Q. Now, just going back to figure 53, there is a statement 'engine timing altered causing rough running'. Do you have some problems with accepting that you would have altered timing on the left-hand engine as a result of the crack in the crankshaft commencing and then propagating, and prior to the complete separation of the crankshaft at the big-end cap.
A. Yes, I do because assuming that the bearing didn't fail some 50 hours or so before, assuming the bearing was intact, that's the No. 6 big-end bearing, when the journal cracked you would have the clamping effect of the big-end bearing that holds the two pieces together gradually being chopped out. There would be almost no movement between the two pieces and you would need a relatively significant amount of movement, at least two or three millimetres, I suppose, I haven't measured it, to have any effect on the engine timing. It would need the alignment of the crankshaft to be changed somewhat, two pieces to be changed. I just can't see how it could happen. Perhaps towards the very end after the bearing inserts had been chopped completely there might be some slight change, but I would have thought that it would be absolutely minimal.
Q. So, the concept of getting altered timing through the cracking of the crankshaft, in your opinion, is a very remote possibility.
A. Well, I found it unconvincing.
Q. I think we can now go to figure 51 or p.82. At p.6 of C210, I think you pick up this point that in the engine failure sequence diagram at p.51, if we go to the right-hand side, we get a statement to the effect in one of the boxes or the second box from the bottom 'loss of performance five cylinder operation', see that.
A. Yes, I do.
Q. On the left-hand engine, do you see any reasonable hypothesis for saying that at some stage that engine was operating only on five cylinders.
A. Nothing's impossible but when I looked at the mechanical damage incurred on the engine, the left engine following the failure, the conrod, the big-end bearing cap, the engine stopped basically immediately and that would be consistent with the damage that was seen on that engine.
Q. So once the big-end cap let go, within very quick proximity you've got absolute cessation of operation of that left engine.
A. Well, certainly that's my view, and I know at the time, the engines were being torn down I spoke a number of times with some of the investigators involved in the process, they all agreed it would have been instantaneous failure.
Q. And are you aware that the conrod went through the crankcase and in fact through the oil gallery.
A. Yes, that's right.
Q. I think that your view is that the pilot may have either feathered that engine himself, or there is a possibility it may have gone into feather as a result of the oil loss, but that is something on which there could be various opinions.
A. Yes.
Q. Can you tell his Honour what your view is.
A. With a loss the oil pressure certainly the propeller would move to the feather position. There are stops to stop the propeller blades going to feather when you shut down the engine. I'm not sure of the mechanism now, it may have happened automatically without the pilot feathering manually, or the pilot may have actually manually feathered the propeller, one way or the other it was certainly feathered.
Q. Would you agree with me, if a pilot realised he had a catastrophic problem with an engine it would be prudent for him to feather it.
A. Very much so. You're going to get the least amount of drag from the feathered propeller.
Q. So, in respect to the operation of the left engine on five cylinders, you see that as a remote possibility.
A. Yes, I don't see how that could have happened.
Q. So therefore if we look at figure 53 and we go to top of climb to top of descent you do see, as you've already indicated, a slow deterioration in performance or arguably there could be interpreted from that a slow deterioration in performance of the aircraft.
A. Yes.
Q. Is it your opinion that you cannot attribute that slow performance to the left-hand engine on the facts known to you.
A. That's the case.
Q. So, that being the case, if it is attributable to any engine, would you agree with me it's more likely to be attributed to the right engine.
A. It would be attributable to the right engine, assuming the loss of performance was due to an engine problem, and I think all the evidence would point the that. I could not understand why the pilot would just deliberately slow the aeroplane down; he's on a scheduled flight, there would be no reason to do this.
Q. You might help us on this. We've had a lot of evidence regarding the change of heading at 1847:15 which is on p.3 of the final report C97, you've given that a good deal of consideration yourself.
A. Yes, they talk about the change of heading, I'm not quite sure how it can be said there was a change of heading. There probably was, but, my understanding is, from my reading of the final report and certainly with the draft report, that the radar data only provides, as far as the report is concerned, speed, altitude, and track, ground track rather than aircraft heading. Now, most certainly there would have been some sort of heading change to create a track change, but it's not correct to talk about the aircraft heading change, you can only say that the aircraft track changed, that's my understanding of the information available from the radar.
Q. Can you tell his Honour what other possibilities, other than loss of performance of one or other of the engines, may have resulted in the aircraft changing direction.
A. It could have been purely due to navigational correction, there would be no other reason, I can't imagine.
Q. We do also have, at that stage, a loss of approximately eight to ten knots.
A. That's right. The pilot may, certainly would have been, I believe, having problems with an engine, the right engine and he may well have been somewhat distracted, the aeroplane drifted a little off track or changed its track, I don't think it's of great significance at that stage.
Q. But you agree that one scenario is that at that stage the pilot has identified problems with the right engine and is troubleshooting.
A. It would seem likely that that would be the scenario that would fit the circumstances we see here.
Q. One of the things that he could have done would have been to reduce power on the right engine, if there was some problems with the right engine and increased power on his left engine.
A. Yes, as far as the pilot is concerned, based on my experience as a pilot, you would go through some sort of trouble check. There was a troublechecking procedure in the pilot operating handbook, that might take some minutes to do that, and it would be more than likely that if you can't identify what the problem is and correct it, then more likely you probably reduce the power on the right engine and perhaps increase the power on the left to compensate somewhat.
Q. If one accepts that the audio analysis at top of descent revealed rpm in one or both engines of 2400, would that fit the scenario of powering back on the right engine, but increasing the revs or the rpm so it's in sync with the left engine and also increasing the left engine to 2400.
A. Yes, it could be that the pilot elected to select climb power, or it's equivalent, on the left engine that would be 2400 revs and probably 36 inches of manifold pressure, or something like that. He's reduced the power on the right engine, and to minimise concern the passengers it would be conceivable that the pilot would also increase the rpm on the right propeller to match that of the left, take out this out of sync beat, it could be quite upsetting.
Q. That could account for the true airspeed being up in the vicinity of 147 knots.
A. Yes, it could be something in that, yes.
Q. Would you expect the Piper Chieftain aircraft on one engine to be able to achieve a speed of 147 knots.]
A. A true airspeed?
Q. Yes.
A. No, and I requested one of my investigators to make inquiries about that and we received data from the aircraft manufacturer, from memory, which indicated, from memory, the maximum true airspeed that could be gained would be about 141 knots and depending on which tailwind component you're using it would either be 154 knots or 161 knots, groundspeed, whereas the minimum groundspeed I think recorded was somewhere in the order of 165, 167 knots in the cruise sector. That indicated to me that the aircraft was not operating solely on one engine, it was operating with two engines operating but with one, more than likely, reduced in power and perhaps compensated somewhat by the other engine.
CONTINUED
Q. When we get to top of descent, we know that the pilot called in in an apparent normal manner, indicating he was at top of descent and he was going to proceed to land at Whyalla and the profile of the descent at the beginning is approximately 400 feet loss of altitude per minute as he descends; is that to the best of your knowledge, an appropriate descent profile.
A. Yes, that's not unusual in those conditions.
Q. Then it proceeds to 650 feet per minute, and soon after that, there is the mayday call indicating double engine failure.
A. Yes.
Q. And just on that scenario, if we assume that there were two engines operating at top of descent, albeit one with reduced power, is there a scenario where the pilot may have left the engines in that configuration or is there a possibility that he may have closed down the right engine.
A. Well, it would be my opinion that the pilot, because he couldn't correct the problem, he's not sure of what the problem is on the right engine, he's been able to reach the top of descent point rather than perhaps cause unnecessary damage or further damage to the right engine, it would be quite conceivable that he would have deliberately shut down the right engine, because he would have expected that a left engine would be capable of providing sufficient performance for the aeroplane to safely arrive at Whyalla.
Q. And I think you accept that at time of ditching the right engine was developing some power in that the propellers were not feathered, and appeared to be rotating.
A. Yes, that's the case, the final report does suggest that, that the propeller blades were in a normal flight region.
Q. And if that's the case, if he shut the right engine down, he's then got it going again, at what stage we don't know.
A. We don't know that, but it would be somewhat difficult to get it going, but not impossible. The engine was capable of, in my opinion, of operating, albeit at reduced power.
Q. Ah alternatively, if he didn't shut it down and get it going, it was operating at such power that he was unable to prevent the plane from ditching.
A. Yes, that's right. There wouldn't have been adequate performance on the right engine to reach Whyalla.
Q. Going back to p.7 of your summary of the final report of C210, you there refer to the findings that the analysis of the fuel revealed and you recorded in your draft report and how that appears to change in the final report. Can you just explain why you believe that's worthy of comment.
A. It was something that I noted that in the report that I prepared. I wrote 'Laboratory analysis of the recovered fuel samples identified the fuel as Avgas 100 LL' which in this case is low load specification, whereas in the later final report that says 'The test data was typical of aviation gas' or Avgas if you like '100/130' which is 100, 30 octane and I was just curious about that. Perhaps I'd made a mistake but to the best of my knowledge I would not have indicated it was '100 low load' without actually having seen the laboratory report.
Q. And low led in your opinion, would that be less likely to produce lead oxybromides.
A. Well, at a fairly simple level I thought that would be the case, it would reduce the incidence of that sort of event happening.
Q. You go on at p.8 to deal with your opinion based on the evidence available to you, the more likely sequence of events that led to the failure of the left engine is that and you say 'that the crack initiated due to some defect in the manufacture of the crankshaft'. I take it that you make that comment after you've been aware that there will be recalls, some three mandatory recalls of crankshafts.
A. Yes. that's right. That's with the benefit of hindsight you could say. But in my opinion, the sequence of what I have listed there is more likely, if it's the other data or evidence that became available during the investigation.
Q. And indeed, when you were compiling the draft report, did you give consideration to there being a defect in the manufacture of the left crankshaft.
A. I'm sure it was something that would have been discussed in the normal course of the investigation, but, you know, I obviously had to take advice from the experts and I accepted the fact that, or the advice that it was a bearing failure that initiated this whole process rather than some other latent manufacturing problem.
Q. And you are now aware there is quite enthusiastic debate between metallurgists as to whether or not there was a defect in the crankshaft or there wasn't.
A. Yes, I have been told that. I'm not aware of all of the detail.
Q. However, defective left-hand crankshaft in your opinion is the most probable hypothesis to explain what happened to the left engine.
A. That's my opinion.
Q. You then go on to make some comments to assist his Honour regarding the right engine and can you just summarise what you think is the most likely scenario on the known facts regarding the right engine.
A. It appears to me that at some stage prior to the final flight, whether it was one particular event or a series of events, that the right engine, the combustion chambers were exposed to higher than normal temperatures; this may have had something to do with the way the mixture was being leaned in climb. There was an event which I have detailed in my additional statement that happened the day before the accident flight where the aircraft was being ferried from Port Lincoln to Whyalla where the trend monitoring data indicated exceptionally low fuel flow reading on the right engine, and a power setting which was about the normal cruise power setting, and it made me wonder whether there may have been damage caused to certainly the No. 6 piston from that incident and that episode which was detailed in the draft report which was not mentioned in the final report. Eventually anyway during the final flight, probably shortly after the aircraft reached cruise, a hole developed in the piston wall of the No. 6 piston of the right engine, and it's progressed, probably got a little bit larger as the flight continued. It's more than likely the pilot would have tried to carry out trouble checks to try and correct the problem. He couldn't do that. It's more than likely he's reduced power on the right engine trying to save it, until he was in a position where he could shut it down and still make Whyalla safety and that would have been shortly after reaching the top of descent. It seems as though very shortly after that, the left engine failed completely and without warning, causing the pilot to report 'We've got no engines' and during the subsequent descent he's more than likely got the engine restarted, wouldn't have been delivering sufficient power for the aircraft to reach Whyalla but it was evident from other evidence that the right engine was delivering some power at the time the aircraft entered the sea.
Q. Just dealing with that scenario, if at the top of climb the No. 6 piston was holed, and power was subsequently reduced on that engine, what do you say would have happened in respect of the venting of the oil overboard; would that have been lessened because the power was reduced.
A. Yes. Clearly if you reduce the power it's going to reduce the pressurisation of the crankcase and that's going to reduce the amount of oil being vented overboard and maybe initially it was quite a small hole so that all this could have taken quite some time to exhaust the oil; could have taken some hours. It's impossible to know exactly how long that process would have taken, but it's likely that the engine started to deteriorate just shortly after the aircraft reached top of climb rather than at top of climb. I think the aeroplane was seen to accelerate on the radar on to its normal cruising speed and maybe at that time the pilot was just setting the mixtures for cruise, and that may have been the final event that resulted in this holing of the piston. I'm not suggesting that it was solely that action. It was just the final straw that broke the camel's back so to speak.
Q. Just dealing with what you would expect a competent pilot to do in the event of certain scenarios presenting to him this flight. If you accept the scenario that at 1847:15 he had a catastrophic loss of the left engine, would you have expected a professional pile to have made a pan call.
A. Yes, very much so
Q. Whereas if just after top of climb there had been some malfunction in the right engine, but it was still delivering power, and he was able to - say he had a hot cylinder or an excessive cylinder head temperature reading, but on knocking the power back that temperature dropped, so the engine was still operating, albeit with reduced power, but he had a left engine that was apparently operating efficiently, and he knew was only 262 hours old, would you expect him to make a pan call with that set of circumstances confronting him.
A. Initially I would have expected a pilot to try and find out what the problem was. The right engine would be probably running a little roughly, could be due to a number of reasons. He would go through his trouble checks. Clearly he wouldn't have been able to correct the problem. He wouldn't know that it was a holed piston. He would know that it was certainly running a little roughly, wasn't developing as much power as it was before. It's likely he would have continued with the reduced power. I would have thought that it would have been better for the pilot to have given a pan call at that point; he evidently didn't. He may have thought that it wasn't a major problem; might have been perhaps a couple of spark plugs on one cylinder out are or for whatever reason, I don't know, but he may not have considered it to be a major problem. He just elected to nurse the right engine and then they could sort it out when they got to Whyalla.
Q. So on that scenario, that is reduced performance in the right engine, but apparent full efficiency in the left engine, it's more understandable that a pilot would not make a pan call.
A. Yes.
Q. There are a number of matters you have referred to in your supplementary report C210. One of them is that there were observations made by farmers close to, in the vicinity of Alford, which is just prior to the aircraft going over the coast, in your opinion if there was a hole in No.6 piston on the right engine, would that plane exhibit strange engine noises to an observer on the ground.
A. Well, it would seem likely that would happen, and fairly early on in the investigation we did receive reports, quite independent of each other, from some people in the Alford area, people who I'm told were quite familiar with this aircraft passing over at that particular time of the evening and they both commented, independently of each other, that the engine note sounded differently. That's about all you can conclude from that, but it certainly did fit in with the likely scenario that developed.
Q. One final point, in your draft report at p.52, C73D, you see in the second to last paragraph the report adopts a tailwind component of 13 knots.
A. Yes.
Q. And can you remember what information you had available to you to arrive at that figure.
A. Yes. We looked at the previous flight, in fact it's explained on p.49 just above paragraph 1.18.5.2, that we looked at the previous flight of MZK from Whyalla to Adelaide where the aircraft had cruised at 7,000 feet at an average groundspeed of 154 knots. 'The return flight to Whyalla was made at 6,000 feet' - that's the accident flight - 'at an initial groundspeed of about 180 knots. The wind at 7,000 and 6,000 feet was forecast to be the same. Assuming that the pilot had used similar power settings for both flights, the actual wind effect on the aircraft was calculated to provide a 13 knot tail component for the flight to Whyalla'. And the analysis of the performance of another similar aircraft flying in the area suggested that the wind was generally constant, and so we came up with a figure of about 13 knots. We can't say that that is entirely spot on but it would be a relatively close estimation of what the actual tailwind component was.
Q. And I think that yesterday you were informed that there will be evidence available from a pilot of an Orion aircraft that circled the ditching area approximately 30 minutes after ditching and that he recorded the wind as being at 01 knots, so would that accord with what you worked out.
A. I don't recall hearing that, and I'm not quite sure what the 10 knots means. 10 knot tail component?
Q. Yes.
A. I would accept that if that was the case, the Orion would have sophisticated equipment to measure wind velocity, or the effect of wind velocities.
CONTINUED