ATSB & the search for investigative probity?? – Update 10 April 2015

10 Apr

1374166800000 

Excellent post Gobbles dealers call indeed… Wink

Quote:They ought to as the iceberg is well and truly exposed –  the myriad of QF issues since 2008, Lockhart, Pel Air, REX vs a coal loader, a bent VA ATR that simply defies belief that it never speared in, and the list goes on. The muppets at CAsA like to talk about ‘red flags’. Well there are so many red flags covering the feckin Australian landscape it looks like the crash scene from the Germanwings crash. ICAO and the FAA must be concerned, surely?

Well you’d think so wouldn’t you?? Not so much the smaller flying tin incidents but the Mildura fog incident and a couple of those recent ATC LOSA events you would of thought may have grabbed their attention?? Hmm…maybe there is some sort of filtering going on between the time the original incident report is received & when the official ATSB incident report is forwarded to ICAO for input into the iSTAR database?? Who knows but it is certainly passing strange and we all know that the powers to be have been caught fudging the books before… Blush
Wikileaks: Australia nearly lost its air safety rating
2004 AUDIT REPORT OF THE AUSTRALIAN TRANSPORT SAFETY BUREAU (ATSB)
{Ref: In particular see Appendix 5-1}

Oh well at least we seem to have made some progress to aviation safety reform with the recent release of the 2015 ATSB/CASA MoU – see here or here.

However until such time as someone acknowledges that the muppet Dolan has to go, we will continue to get absolute bullshit statements like this in the joint ATSB/CASA MoU presser…

“…Mr Dolan said, ‘the MOU spells out how the two agencies will cooperate in the interests of improving aviation safety. We are working together – with the ATSB identifying safety issues through its investigations and findings, and CASA and the industry responding to those issues, as appropriate – to promote high standards of aviation safety.’ …”

Those words should – coming from the head of the ATSB – provide reassurance that maybe the worm has turned & after the PelAir cover-up debacle, the ATSB is on the road to recovering some of its former reputation & effectiveness as the Australian air safety watchdog. Unfortunately coming from Dolan – who has absolutely no credibility whatsoever and could not lie straight in bed – they are empty words coupled with much recent evidence (besides PelAir) to the contrary.

To get an idea of the extent of the problem lets look at a couple of recent examples, starting with the progress of the Mildura fog incident investigation. {NB: Except that it was over land the parallels in this incident to the VH-NGA ditching are quite striking}

Quote from the tail end of ATSB investigation AO-2013-100 prelim report:

Quote:Continuing investigation

The investigation is continuing and will examine the:

• provision of information to flight crews from ATS

• ATS policies and procedures affecting the flights

• provision by the operators of information to the respective flight crews

• the basis for the sequencing of the aircraft landings at Mildura

• Bureau of Meteorology meteorological services and products as they applied to these flights

• accuracy of aviation meteorological products in Australia.

The final report is anticipated for release to the public by June 2014. Should any critical safety issues emerge during the intervening period, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations and publish them as required.

Well apparently the fact that a combination of systemic safety issues placed two HCRPT Jets in a severely compromised position – where they very nearly ran out of fuel and had to land in conditions below the published instrument landing minima – is not significant enough for the ATSB to publish any safety recommendations or even safety issues/actions.

But hang on maybe there was something in the 19 December 2013 interim factual report??

Quote:Safety Action

As a result of its developing understanding of the occurrence, the Australian Transport Safety Bureau (ATSB) has commenced the following safety action.

Safety forum regarding the provision of operational information

The ATSB is planning to convene a safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally. This forum is planned to include representatives from the Civil Aviation Safety Authority (CASA), Airservices Australia (Airservices), the Bureau of Meteorology (BoM), the operators of VH-YIR and VH-VYK, and other relevant parties.

The aim of the safety forum is to:

• apprise the participants of the circumstances of this occurrence as understood to date

• identify and analyse any gaps in understanding of the responsibilities and processes for the dissemination of operational information to flight crew, when on the ground and in flight

• discuss/examine options for improving the reliability of the dissemination of operational information to flight crew.

It is anticipated that this forum will take place early in calendar year 2014. The results of the forum will be included in the ATSB’s ongoing scoping of its investigation and, where relevant, included in the final investigation report.

Reliability of aviation weather forecasts

As a result of this and other occurrences involving observed but not forecast weather, the ATSB has commenced research investigation AR-2013-200 Reliability of aviation weather forecasts. This investigation will analyse BoM data across Australian airports, with a focus on those supporting regular public transport operations, and is subject to the availability of long-term data holdings of aviation forecasts and observations.

Analyses will be performed across time, comparing forecast and observed conditions as they affected aircraft arrivals at particular airports. The focus of this examination is limited to observed conditions below specified aviation minima, or other conditions that may result in aircraft exceeding safe limits of operation.

This research investigation is expected to be completed by mid-2014. When complete, the investigation report will be available on the ATSB’s website at www.atsb.gov.au.

Ah yes the infamous “love-in” – so do we get any feedback on how the closed door forum went and what safety actions are proposed by the DIPs?

Quote:Updated: 5 June 2014

As forecast in its interim factual report of 19 December 2013, the ATSB convened a safety forum on 31 March 2014 involving a number of industry participants. The forum identified a number of issues, most of which are pertinent to this occurrence and more widely across the aviation industry. These included:

  • differing levels of expectation in relation to the provision of amended meteorological products
  • inconsistencies in standard aviation reference documentation in relation to the use of meteorological products
  • differing levels of understanding and awareness of the availability of meteorological products, including limitations relating to automated weather broadcast systems
  • the effect of international obligations and restrictions on the provision to flight crews of updated weather information
  • limitations associated with the staged introduction of new technologies
  • the need for a coordinated education program to update and deconstruct many long held beliefs and misconceptions within the aviation industry.

The investigation is continuing, with the majority of the initial evidence collection complete. In addition to its analysis of this initial evidence, the ATSB is continuing to work with sections of the aviation industry to enhance its understanding of the issues that were identified at the safety forum and identify any safety issues. This additional work, and any implications for aviation safety, will be included the ATSB’s final investigation report, which is now expected to be released to the public in November 2014.

Should any significant safety issues emerge during the intervening period, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations and publish them as required.

Okay so presumably the DIPs have commenced/proposed safety action so why is this not published or at least acknowledged?? And what has happened to the final report – don’t tell me we have got another bloody PelAir??

Hang on here was an update courtesy of Hoody Big Grin :



Then..

Quote:Updated: 10 November 2014

Completion of the draft investigation report has been delayed due to further evidence collection. It is now anticipated that the draft report will be released to directly involved parties (DIP) for comment in December 2014. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in March 2015.

Okay but wait there’s more.. Sleepy zzzzzzz:

Quote:Updated: 25 March 2015

The investigation completion date has been extended to allow for the examination and analysis of increasingly complex data and information. Additional resources have been allocated to the investigation team, in part, to examine a number of subsequent occurrences that have potentially similar factors with the Mildura occurrence.
Following the safety forum that was convened with industry last year, the ATSB continues to work closely with relevant sections of the aviation industry to address the issues that were identified at the forum and to promote safety action.
ATSB anticipates the final report will be released to the public in August 2015.

Oh (part in bold) I feel so much better for knowing that…FFS Angry

MTF…P2 Confused

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