The search for investigative probity.

The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Peetwo - 07-10-2017

Willow spots the trend at Mildura & Adelaide - Dodgy

Remember when Dave Wilson from the ATSB first embarked on his crusade to ensure we never have another embarrassing, or (worse) tragic, Mildura fog duck-up?

Here is a reminder: Reference - Finally some Reason in the ATSB nuthouse &/or Hoody moves away from Beaker's BASR

Quote:Ground-breaking aviation research to reduce unforecast weather risks

ATSB senior research analyst Dave Wilson is working on a research investigation that will raise awareness of potential weather-related risks among pilots and also examine the effectiveness of rules that have been in place for more than 30 years.

Weather planning rules in Australia are unique compared to countries in Europe and North America. Because weather in Australia is generally good, risks are very low. But when weather is unsuitable for landing, these differences can have a real world effect on aircraft operations. It is these effects that Dave’s research aims to quantify.

A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding and, in some cases, landing below published safe limits. Dave’s research is seeking to understand how the reliability of weather forecasts affects the ability of flight crew to conduct safe landings.

“I want to help decrease the likelihood of pilots being exposed to unexpected and unsuitable conditions for landing,” Dave said. “The likelihood of an accident happening because of conditions unsuitable for landing is low. But in making it even lower, the probability of a major accident happening reduces considerably.

“Initially I’m looking at Mildura and Adelaide airports. At Mildura, 99 per cent of the time, the weather is suitable to land a large aircraft. But based on the data I’ve looked at, there is still a remote possibility you may have an unreliable forecast. With the volume of air traffic, this could affect up to four aircraft per year.

“If you look at Adelaide, the chances of a single flight crew being exposed to an unreliable forecast are lower. However, when you take into account fluctuations in weather reliability, and the aircraft traffic arrival patterns (around 50,000 per year), the potential to result in a catastrophic accident increases. That’s what we want to avoid.

“If you’re in the air and you get to the point of last safe diversion—where you’ll be committed to landing at the planned destination—if the current forecast predicts marginal conditions, questions are raised as to whether continuing to the planned destination or diverting to an alternate destination should be required. This scenario has been a particular focus of this research.”

Dave has a vested interest in his research. Several actually. He’s a pilot who first flew solo when he was a 15-year-old student at Caringbah High in Sydney—well before he could legally drive. The opportunity of subsidised flying with the Australian Air Force Cadets was too good to knock back. He has since flown aerobatics out of Bankstown Airport but has undertaken little flying over past two years while pursuing this research.

Dave also has degrees in Aeronautical Engineering and Physics from Sydney University. It was there he attended a guest lecture by Pierre Blais from the Directorate of Defence Aviation and Air Force Safety (DDAAFS), which set him on a path to the ATSB.

“It was then that I thought investigating aviation safety would provide the ultimate career path for me. I find it both meaningful and challenging,” Dave said.

The research was initially going to secure Dave a Master’s degree. But he is now upping the ante and aiming to pursue a Doctorate. A stumbling block is finding reviewers with sufficient expertise in a related field. When you’re breaking new ground, this is often the case.

After first working at the Department of Infrastructure as a vehicle compliance engineer, Dave came to the ATSB to embrace his love of aircraft, engineering and how things work. Now with six years under his belt, Dave is also considering his future. “I’m happy as long as I’m being challenged,” he said. “But after this research is completed, I wouldn’t mind also undertaking a broader range of transport safety investigations.”

Research on Adelaide and Mildura aerodromes is expected to be published by the end of 2016. Progressive reports for each major aerodrome in Australia and four of our remote island aerodromes (Norfolk, Cocos, Christmas and Lord Howe) will be progressively released over the next year or two.

Last update 18 October 2016

Well apparently Willow (nearly 9 months later) has discovered the holy grail of safety risk mitigation for unforecast wx events at 2 airports within the Australian FIR... Rolleyes

Via Hoody's media minions today:

Quote:New research doubles chances of landing safely in unforecast weather

New ground-breaking research released by the ATSB is expected to double the chances of aircraft landing safely during times of unforecast weather. This is the first report in a series covering Australian airports supporting regular passenger transport operations.

The ATSB investigator leading the research project, Dave Wilson, has analysed an enormous amount of weather and aerodrome data to identify weather-related safety risks for Adelaide and Mildura airports.

Mr Wilson said there were around 50,000 arrivals at Adelaide each year. The likelihood of encountering unforecast weather and having to adopt a contingency plan, such as diverting, was a rare occurrence—about one in 3000.

By developing sophisticated algorithms from the data, the research makes arrival without sufficient warning even rarer—perhaps as low as one in 10,000.

In so doing, the predictive nature of the research means enhanced safety for the travelling public in Australia.

“By reducing the number of aircraft being caught out, we significantly reduce the chance that something will go wrong,” Mr Wilson said.

“As an example, if you take mornings in Adelaide, retrieving a forecast an hour out from landing could double the chance of a safe arrival compared to three hours out,” Mr Wilson said.

“Every year there are circumstances where forecasts don’t provide sufficient warning for pilots. This means they have to divert or, in some rare cases, land below specified limits with critically low fuel levels.”

This occurred in 2013 when two Boeing 737-800 aircraft were forced to divert to Mildura from landing at Adelaide, where poor weather was also encountered. One of these aircraft landed below the specified safe limits with limited fuel remaining.

The research will benefit all aviation operators but, purely due to the number of flights, will be more useful for high capacity commercial transport. Operators will be able to use the research to help guide operational staff such as dispatchers, who support their pilots by helping to focus attention on high risk times of day and seasons of the year.

It will also be of strategic use to the Civil Aviation Safety Authority, Airservices Australia and the Bureau of Meteorology.

“We can identify high-risk locations and high-risk times of day and year, and when this is used with flight planning and operational rules for landing, safety can be enhanced. It will also allow for better decision-making with respect to the prioritisation of investment decisions about aircraft and aerodrome navigational equipment,” Mr Wilson said.

This research is tangible evidence of the direction in which ATSB Chief Commissioner Greg Hood wants to take the organisation.

“The ATSB is committed to becoming a data-driven, predictive transport safety investigator,” Mr Hood said. “We will continue to source data nationally on aviation transport safety occurrences and events and use that data to identify and communicate safety risks and emerging trends.”

Over the next two years Mr Wilson will expand his research and evaluate billions of rows of data to produce a series of reports documenting weather-related safety risks for regions around Australia. The research ultimately has the potential to be applied not only in Australia, but around the world.

Read research report.

Last update 10 July 2017

At this rate this 17+ year identified safety issue will be effectively risk mitigated just in time for Willow retirement age with his ground breaking research - UDB! Dodgy

FDS before we waste another motza of long suffering ATP money on this WOFTAM project - please, please, anyone in power that can overrule Hood and our NFI miniscule 6D, please re-read K O&O post #138:

Quote:Bucket please - just read #

The cynical beast roars WTF in protest as I read the latest ‘puff piece’ from ATSB. The urge to vomit at the soft sell of ‘Dave the Saviour’ reads as though it was written to be inserted between recipes and advice on how best to remove stains from underwear in one of those journals for the mentally challenged, they leave lying about in waiting rooms (does anyone actually pay hard earned for that crap?).

Anywhere else on the planet the simple rule of 1, 2, 3 applies to your pre flight fuel planning (in broad terms)

IFR Alternate Airports (1-2-3 Rule).

When filing an IFR flight plan, you must include an alternate destination airport when the weather forecast at your original destination predicts conditions below those specified in CFR 91.169. To help remember those conditions, you can use the 1-2-3 rule.

1 - During the time 1 hour before to 1 hour after the estimated arrival time

2 - Ceiling less than 2,000 feet

3 - Visibility less than 3 miles

If the above conditions exist, an alternate airport must be filed.
The alternate airport also has requirements that it must meet.
• If the airport has an instrument approach published, the weather must be forecast to be (at the ETA) better than the alternate airport minima specified in that approach or the following standard conditions:
o Precision Approach: 600ft ceiling and 2SM visibility
o Non-Precision Approach: 800ft ceiling and 2SM visibility

Not in Australia – crew are hung out to dry, forced to make all decisions and be legally responsible for ‘getting it wrong’. The BoM factor something like 70% +/- error on their forecast conditions, let the computers do the modelling and waltz off, Scot free, whenever they get it wrong; or, the system fails to get the 'new' information delivered in time for that information to be of any value.

But no matter, our latest new best mate ‘Dave’ is going to do an ‘academic’ study for his degree and we must have the good manners and patience to wait for the results, until he has finished buggering about editing and refining his ‘thesis’, to impress other academics and further his own CV, while we pay him to do so. Bollocks - we don't have the time to fanny about, waiting on his pronouncements.

Pel-Air and the Mildura cock-up tell the tale of organizational and systematic errors very clearly. Only a degree in common or garden sense is required to see the gaping holes in not only the safety net, but in the lines of responsibility. No one has offered a solution, but all, except the flight crew, have gilt edged ‘get out of jail cards’. A company like Qantas have been operating a system of ‘cut out’ points for making diversion decisions for donkeys years now; all the expertise we will ever need is contained within the collective wisdom of their system. Why not ask them, politely, to share that ‘wisdom’ and adopt that advice into law?

I could, if I tried, care a little less about ‘Dave’s’ ambition and his aerobatic experience. This fluffy little bit of scripted bullshit typifies the standard approach to any and all ‘operational’ problems. Anything will do but address the problem head on and sort it out, quickly, effectively and properly.

I tire of the Hood ‘touchy- feely’, soft –softly, apologetic approach: that ducking ‘correcting the record’ thing they do is too pathetic to even be risible. Does he not realize that the organization he runs is a sad, sorry, failed, bloodless imitation, a sick parody of what it is meant to be.

"Ground-breaking aviation research to reduce incorrectly forecast weather risks".

Bollocks !

Enuff said MTF...P2 Undecided

RE: The search for investigative probity. - Kharon - 07-10-2017

‘Tis the seasonTo be foggy, Fal la la la la la la la
Don we now our Hi viz jackets
Fog research will make us packets Fal la la la la la la la
As we write our masters thesis; Fal la la la la la la la

#

What's the use of wearing braces,
Hats or spats or boots with laces,
Coats and vests you buy in places
Down on Brompton Road?
What's the use of shirts of cotton,
Studs that always get forgotten?
These affairs are simply rotten--
Better far is fog.

#

I like aeroplane claptrap;
Aeroplane clap trap for me;
It pays for brekky,
It pays for my tea
A little each day is a good recipie
I like aeroplane clap trap
Aeroplane clap trap for me....

#

RE: The search for investigative probity. - Peetwo - 07-11-2017

PT weighs into Willow's data-driven report - Rolleyes

Via PT today:

Quote:ATSB writes massive report avoiding key issue in 2013 Mildura fog crisis

Somehow the ATSB has done a research report on the Mildura fog crisis of 2013 that doesn't mention the 737s didn't have to carry enough fuel to prevent it happening

Ben Sandilands

ATSB Mildura Fog follow up report cover

The ATSB has just covered the Mildura fog crisis that involved Virgin Australia and Qantas 737s landing blind at the rural airport four years ago because they didn’t have enough fuel to go anywhere else, under a blanket of first class but irrelevant research.

The new research report doesn’t deal with the fact that it is permissible for domestic airliners in this country to set off on flights between cities without sufficient fuel to reach a planned alternative airport if the weather prevents them landing at their intended destination within the regulated safe minimums in terms of visibility and other conditions.

On June 18, 2013, the Qantas and Virgin flights found that they couldn’t meet those requirements because of an unforecast fog at Adelaide airport and elected to land at Mildura instead, which was within reach of their remaining fuel. However unforecast fog at Mildura saw both jets land at the country town without enough fuel to do anything else.

The upshot of various missed approaches by the jets was that the Virgin 737 eventually had to land despite considerable uncertainty as to whether it would find the runway, with the cabin prepped for a crash landing, passengers in the brace position, and calls of ‘brace, brace,brace’ from the flight attendants.

In its final report into those incidents, published last year, the ATSB said both flight crews uploaded sufficient fuel for the originally-forecast conditions in accordance with their operators’ fuel policy and the Civil Aviation Safety Authority requirements.

However the ATSB failed to inquire, in breach of its obvious responsibility to do so, into the adequacy of the Australian fuel requirements for such flights. It was severely criticised by some pilots and safety analysts at the time for its gutlessness.

That administrative cowardice extends to today’s release of a study entitled The effect of Australian aviation weather forecasts on aircraft operations: Adelaide and Mildura airports.

Today’s research release is of course first class in its compilation and execution, but structured no doubt by total coincidence, to avoid the blindingly obvious need to examine the adequacy of the fuel rules followed by Qantas and Virgin Australia on the morning of the Mildura crisis.

The 177 page research report published today says that in relation to Adelaide and Mildura (and we dare to suggest every other jet capable airport in Australia) it is relatively more important that forecasts are retrieved at the latest possible time (before the point where a diversion is no longer possible) prior to arrival.

Will this research publication fool anyone? No. It could have been subtitled How to avoid going too far up sh*t creek when the unforecast weather threatens to close airfields you never thought you’d need to land on because you really don’t have the fuel to do anything else. Two Australian passenger jets were put in harms way by inadequate fuel rules. Had developed world standards for these been in force, both jets would have diverted to more distant airports, such as at Melbourne, or Sydney, or perhaps a more distant jet runway equipped country town than Mildura that was fog free.

MTF...P2

Ps Reckon "K" could get another verse at least from that... Wink

RE: The search for investigative probity. - Kharon - 07-12-2017

PR, PC, Puff pieces and pillow talk.

This little puff piece of pointless research typifies the ministers approach; showy, fools the punters, gets him into the press and achieves absolutely SFA. It may well serve to impress other academics and slot into a thesis, it may give that well known Hi Viz show pony something to show his peers; but to a working airman? It's Bollocks.

A real ‘academic’ piece of research would involve ‘industry’. We all know forecasting the weather, is not an exact science – a fact the BoM gain much wriggle room from, but the level of inaccuracy could be estimated, quite concisely, from log book or even company records. How many diversions; how many missed approaches; how many second attempts successful, how many failed etc. A long study would arrive at the same conclusions we all reached a century ago – a forecast is a good guide – but not good enough to bet the farm on. Never was, unlikely to ever be so; which is why the PIC always has his nuts in a sling, when trumps turn to shit.

The word shit actually is an acronym: Ship High In Transit. The letters stencilled onto the sacks of manure transported around the coast to supply market gardens. They used to store it in the lower decks, and when it mixed with bilge water; explosive gas was produced. Some half wit with a candle or lantern, sent down to inspect the cargo provided the resulting detonation. The government acted and declared that manure must be Shipped High In Transit, that missive to be stencilled on every sack. The moral of the story is a simple one; with some education and sensible government intervention; it is possible to prevent exploding shit from happening. Alas…….

Personally, I am rapidly approaching the stage where I simply will not waste precious time reading the ATSB reports on accidents. Accidents which happen in America, the UK and Europe are similar, the reports mostly of value. It would be quicker and easier to form one’s own opinion of what occurred and be happy with the result. ATSB under Dolan was dreadful; but now, acting as Daren 6D’s PR, PC dancing dog in a dog and pony show; it defies description. Somebody, anybody, get a rope on this outfit, before it gets someone hurt.

Toot toot

RE: The search for investigative probity. - Peetwo - 07-13-2017

Update to Willow's WOFTAM waffle report (the www.report)- Rolleyes

The comments from the Planetalking article are IMO well worth regurgitating... Wink

Quote:

[b]James Nixon[/b]
July 11, 2017 at 3:23 pm
I call it “the cleanest third world country in the world”.
After 31 years in the industry I am still amazed that an Australian A380 can fly from Dubai to Sydney and not have to carry an Alternate because of a CASA “Grandfather Clause”.
This saves them carrying 20 tonnes of fuel every day compared to international airlines, and has resulted at least one declaration of emergency so they could land below minima. That flight didn’t even have enough fuel to divert to Canberra.
Twice inbound Australian international flights have had to declare emergencies when arriving at Perth after unforecast weather materialised. One flight, from Singapore, Pilots even discussed ditching until a paxing Captain convinced them otherwise.
Despite being called (behind their backs) “AUSTR-ONAUTS” for their pedantic ways, Australian pilots routinely set off to destinations in Australia without carrying enough fuel to reach an alternate airport, carrying only enough to cover and INTER or TEMPO for bad weather.
But they don’t get it. It’s not only weather that can cause troubles. The better the weather, the more light planes out and about.
One day, before flying from Alice Springs to Darwin, a Flight Engineer and I had to work really hard to convince a new Captain to carry enough fuel to get to Katherine if anything went wrong. He was terrified he would “be called in the office” for carrying extra fuel.
We arrived in Darwin, on short final for 11, to see a Cessna 210 brake off a wheel and spin on the runway in front of us. Going around from fifty feet, we had only seven minutes of fuel before we were committed to fly to Katherine.
Thankfully, the Cessna pilot dragged his wreck off onto the cross runway, the men in the little yellow car removed the wheel; and our passengers reached their destination.
Had my Captain taken his planned fuel, and had the Cessna suffered a more debilitating arrival; we would have had to land over the wreckage on whatever runway remained.
Fog is the enemy in Australia, a country that talks big about air safety, but only has two Cat 3B runways. When you fly into third world countries that have better facilities you wonder: “So does that make my country, Australia, the 4th, or 5th, world?”
Pilots: if they don’t give you a Lo Vis licence and Cat 3B runways, cover your backside with fuel to go somewhere else. Not 200 kgs on every flight “for Mum” (200 kgs gets you no-where and is not going to help your Mum); but enough for a realistic alternate.
And if they want to call you in the office for it, great. Get them to put it in writing. Take pics of every document, then contact Ben Sandilands or me.
We’ll make you famous for sticking-up for your passengers.
As Don Kendell once told me: “I haven’t spent 20 years building my company so you can turn a Metro into a rotary hoe, 20 miles west of Hamilton. Take The Fuel”.
He was a very wise man.
James Nixon
http://www.TheCrashOfMH370.com

[b]Dan Dair[/b]
July 11, 2017 at 8:35 pm
Australia is flying 21st century, state-of-the-art aircraft,
with fuel-alternative rules that were ‘cutting-edge’ in the late 1950’s.!!!
(& with an unfeasably large number of airfields served by passenger jets, with no control tower, ILS, fire-service or effective weather monitoring….. but hey, she’ll be right.?)

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[b]JW (Aka James Wilson)[/b]
July 11, 2017 at 4:04 pm
Jesus wept! A 177-page report to state something that’s blindingly bloody obvious. What a waste of taxpayer dollars.
[/size]

[b]Resolute[/b]
July 11, 2017 at 11:13 pm
Yep very true

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[b]Comet[/b]
July 11, 2017 at 5:27 pm
So now we have to follow the money trail to discover the reasons the ATSB refuses to perform its duty.
Royal Commission needed.
[/size]

[b]Dan Dair[/b]
July 11, 2017 at 6:52 pm
….or proper, old-school investigative journalism in the Australian mass-media.?

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[b]Dan Dair[/b]
July 11, 2017 at 7:32 pm
I wonder from where the ATSB could acquire such a devious plan……….
Sir Humphrey Appleby to Jim Hacker:
“Put the problem in the title of the report, thus avoiding any further need to refer to it in the text”
The ‘Yes Minister’ school of action-avoidance.
[/size]

[b]Resolute[/b]
July 11, 2017 at 11:09 pm
“doesn’t mention the 737s didn’t have to carry enough fuel to prevent it happening”
Exactly Ben !
CASA is always very good at arse covering.

[b]Chris Randal[/b]
July 11, 2017 at 11:47 pm
Whilst you could be correct it is more that fact that Australia seems to believe that the appropriate NAVAIDS/Approaches are available/developed.
The fault is NOT with the carriers – it is with CASA and their masters, and the fact that the motive for those running airports is profit NOT safety.
Even WLG and CHC have ILS approaches and ZQN has an RNP approach. What does BNE/ADL/any other airport in Australia have?

[b]Chris Randal[/b]
July 12, 2017 at 2:19 am
Sorry – I’ll rephrase the first paragraph:
“Whilst you could be correct it is more that fact that Australia seems to believe that the appropriate NAVAIDS/Approaches are not required”

[b]JW (Aka James Wilson)[/b]
July 12, 2017 at 10:45 am
Your comparison with New Zealand airports is not valid. BNE, ADL and other ‘large’ city airports in Australia have ILS approaches, but only MEL (and soon PER) has a full CAT IIIB ILS approach that allows landing in very low visibility conditions. The others only allow landings where the visibility is at least 550m, or in some cases higher. New Zealand is no better off than Australia – the only CAT IIIB approach is in Auckland. The approaches at WLG, CHC and ZQN do not allow landings in low visibility conditions (ie less than 550m).

[b]Dan Dair[/b]
July 12, 2017 at 11:22 am
James,
Are there any figures available on just how much the new ILS system at Perth will cost.?

[b]JW (Aka James Wilson)[/b]
July 12, 2017 at 4:05 pm
I believe the total cost of the upgrade is about $36 million. Most of that cost isn’t actually the ILS upgrade; it’s the lighting infrastructure and transmissometers that are required to support low visibility operations.

[size=undefined]
[b]Dan Dair[/b]
July 12, 2017 at 11:20 am
“The fault is NOT with the carriers”
Whilst agreeing that it is CASA who should be providing the lead on this matter, by requiring proper fuelling for an alternate airfield, in line with normal world standards,
I’ll take issue with it being ONLY about CASA & not the airlines.
Independently, any airline COULD choose to fly with enough fuel for a proper alternate, but they actively choose not to.
That choice is made every day by virtually all of Australias carriers for the good of their profits
& in direct conflict with claims of the so-called emphasis upon a passenger-safety culture.
I would be extremely surprised if most/any Australian passengers realised that their home airlines don’t carry alternate fuel on a day-to-day basis,
or that this practise is completely within the laws & regulations of Australia.?
I anticipate that most passengers just assume that what they see in TV & films, about diverting to an alternate airport is what happens at home as a matter of course,
and this is what their plane will do if the destination becomes unavailable.?
Should the worst ever happen (as it nearly did at Mildura), the airlines will be quick to blame CASA, but this simply won’t wash.
It is the airlines who are putting pressure upon CASA not to tighten the regulations, because they know it will affect short-term profits.
Any airline could take this step & then market it as a safety feature (which it is.!), to attract concerned passengers & shame other airlines into following suit.?
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[b]Dan Dair[/b]
July 12, 2017 at 8:53 am
“unforecast fog at Mildura”
IMO that’s a significant part of the problem.
Mildura isn’t the centre of the universe, but equally it’s not a one horse town.
They have regular jet services as well as a bunch of daily turbo-props.
But what they don’t have, is anyone actually on the ground who could let anyone in the AirServices main control office know that it was a bit foggy there.
So AirServices allowed the two B737’s to divert to Mildura because they thought the weather was OK.?
Actually, they must have KNOWN the weather was OK, otherwise they wouldn’t have let them divert.?
Which is a bit of a shame considering they were completely wrong.!
[/size]

[b]JW (Aka James Wilson)[/b]
July 12, 2017 at 11:13 am
Dan,
The BoM [i]does[/i] have an observer on the ground at Mildura, who reports to the BoM. The BoM then issues the observations and forecasts that are passed to aircraft by AirServices. In this case, AirServices personnel on the ground in Mildura (if they existed) would not have made much difference. If I remember correctly, the BoM observer stated that the fog formed very quickly, by which time the two aircraft were almost overhead Mildura with no fuel to go anywhere else.

[b]Dan Dair[/b]
July 12, 2017 at 11:34 am
I wasn’t there & don’t purport to be definitive on this,
but in my experience Mist forms very quickly.
Fog tends to develop over a period. Indeed Mist may form & then lead to fog later.?
My only experience of ‘instant’ fog is that which happens when you are travelling & move into a ‘fog bank’.
If you’re stationary & the fog exists as a bank, you can see it slowly moving towards you.
If it forms around you. it tends to do it over a period of an hour or hours.
However, whilst I freely admit that I have no idea what is normal & usual for the area around Mildura airport,
I would venture to suggest that the observer may have had his feet-up until ‘the two aircraft were almost overhead’, at which point he started rapidly thinking-up a good excuse.?.

[b]JW (Aka James Wilson)[/b]
July 12, 2017 at 4:09 pm
I wasn’t there either, but the ATSB investigation report into the incident states the following:
“Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m. In addition to the recorded indications, the BoM forecaster received a phone call from ATC asking about the conditions. In response the forecaster contacted the BoM observer located at Mildura Airport. The observer advised the forecasting office that the mist and subsequent fog arrived rapidly from the south.”

[b]Dan Dair[/b]
July 13, 2017 at 6:27 am
James,
“Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m”
So, according to the observer the weather changed from essentially completely clear to totally boxed-in, over a period of just six minutes.?
I refer you back to my previous ‘feet-up’comment.!

[b]Tango[/b]
July 13, 2017 at 8:08 am
Dan: You are being your usual obscured self.
I have seen fog banks move over 2 miles in very short periods of time.
In minutes you can go from totally clear to zero zero.
There is a lot lacking in the system, but with what they had it was what looked like an easy choice.
What I can say is that if you have the instruments, you can both predict and forecast the POSSIBLIY of a sudden fog development or movement.
That certainly was lacking.
My take was I would have taken Adelaide, but then I have a great deal of confidence in my ability to fly instruments, Adelaide had much better setup than Mildura and a diversion with no reserves if iffy at best.

[b]Dan Dair[/b]
July 13, 2017 at 10:18 am
Tang,
I’m not being ‘obscured’.?
JW tells us that the official report says;
“Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m”
28 kilometers is around 17.5 miles. That’s a darned sight more than two miles……
If the observer was actually observing, it’s not unreasonable to imagine that they’d have noticed the weather begin to close-in when they first saw the fog-bank or adverse conditions, around the time that visibility was no-longer at 28km.?
With the benefit of hindsight, Adelaide is a far better option, especially as it ended-up having much better weather than was forecasted.!
But importantly, the two aircrafts’ crews were told by AirServices that Adelaide was fogbound & Mildura was clear, when actually, the reverse turned-out to be true.!

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[b]JW (Aka James Wilson)[/b]
July 12, 2017 at 9:57 pm
I should add, the aircraft arrived overhead Mildura shortly after 0930.
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[b]Dan Dair[/b]
July 13, 2017 at 10:27 am
James,
& I should add that according to the figures you tell us were in the report,
this weather-front closed-in on Mildura at an approximate speed of approaching 300kph or around 180mph.
That’s pyroclastic flow or hurricane pace, not that of a random bit of weather.?

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[b]George Glass[/b]
July 12, 2017 at 5:32 pm
It is difficult to convey to the general public how crap the infrastructure in Australia is. Politicians are terrified of infrastructure. It cost money. It’s in unpopular. Fat better spend money on child care centres. So infrastructure is ignored. Perhaps you could justify Cat 1 20 years ago. Today is delusional. Its exhausting even thinking about how you to explain to the travelling public how exasperating it is for professional aircrew to have to explain delays/ diversions etc. etc. And it all boils down to this; crap infrastructure, weak bureaucracy, know nothing politicians and no forward planning. It’s dangerous, it’s incredibly frustrating for all professionally involved and won’t change until there is a black smoking hole in the ground. The subsequent Royal Commission will be a ripper.[/size]

MTF...P2

RE: The search for investigative probity. - ventus45 - 07-17-2017

Passing strange - Part I

As the former Chief Commissioner of the ATSB enjoys his retirement, he must have smiled with pride, when he read the latest "non report" https://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-100/ on the near disasterous "Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013" issued by his former underlings.

They have indeed, mastered the art, of the "ducking the issue" he mused, as he sipped his coffee, with satisfaction.

The two receomendations are a joke, pure mastery of the fine art of the bloody cop-out, of the first order.
https://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-100/si-01/ and
https://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-100/si-02/

The real issue for "AIr Safety Investigations" is to identify and fix problems that caused accidents, or near accidents, for, hopefully, THE PREVENTION OF (PROBABLE) FUTURE ACCIDENTS.

The ATSB has spectacularly FAILED to achieve that here. It fails to acknowledge the real seriousness, and significance, of the factors at all levels in the modern "Airline System" that created the preconditions that led to the Mildura Incident.

Besides "ducking" those issues, it deliberately fials to consider the potential aftermath of those failures. What all of us worry about, is "What If" the first B-737 to land had have had a problem, an incident, a hard landing, blown a tire or two, left debris on the the runway, or worse, a runway excursion, or an over-run, or even worse, with passengers then spilling out down the slides and scattering all over the airfield, (in the fog) then with local ground staff responding alll over the place ? That would have "fouled" not only the runway, but the entire airfield.

You would have had "mayhem on the airfield", just like when the B-777 crashed in San Francisco, but this time, "in the fog".

How could the second B-737 have got down safely then ?

Answer, it could not have.

If it had attempted to, there would have been a real crash then, a monumental disaster all around.

Would that second B-737 crew have attempted it ? I pray not. As professionals I am confident that they would not have.

They would have swallowed "the deep shit pill", and gone off to an area "in the clear". Hopefully, at least one of the two up front may have been a glider pilot in his younger days. Then the ATSB could write a sanitised report that dismisses the significance of their emegency with:- "the incident crew executed "a routine outlanding" - nothing to worry about M'lud." (with emphasis on the "routine").

The James Nixon post on Crikey says it all. https://blogs.crikey.com.au/planetalking/2017/07/11/atsb-writes-massive-report-avoiding-key-issue-2013-mildura-fog-crisis/#comment-83493
It is reprinted below for all to see.

It will eventually be "Exhibit A", in the now inevitable, but yet to be scheduled, Royal Commision, when we do have a real smoking hole (the heat from which, will at least, clear the fog for the TV-news helicopters).

ENOUGH. I call James Nixon to the stand M'lud.

James Nixon
July 11, 2017 at 3:23 pm

I call it “the cleanest third world country in the world”.

After 31 years in the industry I am still amazed that an Australian A380 can fly from Dubai to Sydney and not have to carry an Alternate because of a CASA “Grandfather Clause”.

This saves them carrying 20 tonnes of fuel every day compared to international airlines, and has resulted at least one declaration of emergency so they could land below minima. That flight didn’t even have enough fuel to divert to Canberra.

Twice inbound Australian international flights have had to declare emergencies when arriving at Perth after unforecast weather materialised. One flight, from Singapore, Pilots even discussed ditching until a paxing Captain convinced them otherwise.

Despite being called (behind their backs) “AUSTR-ONAUTS” for their pedantic ways, Australian pilots routinely set off to destinations in Australia without carrying enough fuel to reach an alternate airport, carrying only enough to cover and INTER or TEMPO for bad weather.

But they don’t get it. It’s not only weather that can cause troubles. The better the weather, the more light planes out and about.

One day, before flying from Alice Springs to Darwin, a Flight Engineer and I had to work really hard to convince a new Captain to carry enough fuel to get to Katherine if anything went wrong. He was terrified he would “be called in the office” for carrying extra fuel.

We arrived in Darwin, on short final for 11, to see a Cessna 210 brake off a wheel and spin on the runway in front of us. Going around from fifty feet, we had only seven minutes of fuel before we were committed to fly to Katherine.

Thankfully, the Cessna pilot dragged his wreck off onto the cross runway, the men in the little yellow car removed the wheel; and our passengers reached their destination.

Had my Captain taken his planned fuel, and had the Cessna suffered a more debilitating arrival; we would have had to land over the wreckage on whatever runway remained.

Fog is the enemy in Australia, a country that talks big about air safety, but only has two Cat 3B runways. When you fly into third world countries that have better facilities you wonder: “So does that make my country, Australia, the 4th, or 5th, world?”

Pilots: if they don’t give you a Lo Vis licence and Cat 3B runways, cover your backside with fuel to go somewhere else. Not 200 kgs on every flight “for Mum” (200 kgs gets you no-where and is not going to help your Mum); but enough for a realistic alternate.

And if they want to call you in the office for it, great. Get them to put it in writing. Take pics of every document, then contact Ben Sandilands or me.

We’ll make you famous for sticking-up for your passengers.

As Don Kendell once told me: “I haven’t spent 20 years building my company so you can turn a Metro into a rotary hoe, 20 miles west of Hamilton. Take The Fuel”.

He was a very wise man.

James Nixon

RE: The search for investigative probity. - thorn bird - 07-17-2017

& Part II

Y'know Ventus, the whole event and the aftermath, and the report, for me, sets off the old "passing strange" gene, not about the incident itself but the inconsistencies in the way the way the "regulator" reacted.

Here we have two crews from our two major airlines, lead into the trap of finding themselves caught between a rock and a hard place, no back door, sucking up leather, and the low fuel lights boring holes in their retinas,
not the first and most certainly not the last to find themselves in that unhappy position.

They broke no rules, followed SOP's and company direction but fate dealt them a horrible hand,
some skilful flying and cool deliberate actions saved the day.

The ATSB fluff piece skilfully swept the inadequate policies and regulatory requirements under the carpet.
All good, nothing to see here, unfortunate incident etc etc and all goes back to normal, crews back to work, big pat on the back, maybe wiser, maybe not, but one thing for sure the industry was denied any lessons that may have been learnt from a whole investigation, including systemic deficiencies that may or may not have existed with the rules, or company procedures or oversight.

Now consider a very similar incident a few years prior.

A young man found himself in that same horrible position. Arriving at his destination with no back door because one wasn't required, the end result somewhat different in that he and his passengers had an unwelcome swim off a remote island in the middle of the night.

Before an investigation had even begun, the sociopathic lunatic in charge of the regulator had very publicly pilloried him.

I cannot imagine that if rules were broken, or SOP's not followed, or company directions ignored, the full weight of the LAW would have descended on him in a very formal court room.

Yet it didn't.

Instead, its not too hard to imagine, given the angry man persona of the CAsA head, that a great deal of pressure was bought to bear on the ATSB to make their subsequently discredited report, agree with his
assessment, "the pilot dunnit" All the other valuable lessons that may been learnt and had a positive safety impact on the whole industry swept aside.

The witch hunt that followed saw severe sanctions placed on the hapless pilot, by way of "administrative" actions which continue to this day.

Whats passing strange is the inconsistency in the way CAsA or should I say the CAsA head reacted to a GA pilot compared with airline pilots.

RE: The search for investigative probity. - Kharon - 07-18-2017

A ramble, from the bottom of the fuel tank.

Good posts "V" and TB, spot on. There are so many things ‘wrong’ related to the Mildura event, before you even begin to analyse the ATSB and CASA whitewash, you have to wonder at the ‘real’ safety state of domestic air services between the capitol cities, from an operational perspective. I finished up last evening with three pages of bullet point headings which really should be addressed, by the airlines. The next step in my mud map analysis was to try and arrive at the reasons why the matters have not been tackled by the operators – in the interest of operational safety and efficiency. The nearest ‘believable’, supportable argument I could justify was ‘compliance’.

Absolute strict compliance with the minimum requirements of black letter law has become the holy grail of AOC holders. It is a seriously difficult task to meet the rigid minimums, once that is achieved and everyone is brainwashed into believing that after meeting them and nothing else but the minimum requirements; then all is well. Thing is, it ain’t; not really, however, any attempt to progress beyond boundaries set as part of the long, weary process of obtaining an operating certificate is fraught with legal peril and great expense. Anything innovative which is proposed may be operationally ‘sound’ but if it steps a little beyond the minimum ‘acceptable’ to the oversighting CASA delegate; then it is doomed. So we struggle on, cursing the ridiculous rules, locked inside an inescapable prism of complex, contrary rules. Gods alone know what the real cost to industry is. In some ways that cost justifies management attitude toward ‘savings’ wherever possible, a thing they are obliged to do. Shareholders get cranky when the returns fail to meet the expectations and promises made.

Sorry, didn’t mean to ramble; but, to a thinking man, Mildura brings into sharp focus the underlying flaws in the entire system. However that was not the purpose of my mud map musings. I started with ‘flight planning’ and the BoM forecast for the day in question; all strictly by the book legal, bullet proof. High risk – operationally – but dead set ‘legal’ until the wheels came off. To me, the forecast conditions indicated ‘fog’, the detail text book classic, would I plan for an alternate? Damn straight I would – no brainer and no hindsight either; but that’s me, I know the routes and the area. But what if I didn’t – or had to justify an additional five ton of fuel – what then- particularly if the whimsical fog failed to oblige ? Tea and biccies perhaps.

There are solutions – non of which the ATSB mention – like low visibility approval; or, improved infrastructure; or, even improved forecasts and reporting. How come the story always ends the same way; BoM spotless: ATSB nugatory: CASA waiting with a bloody big stick: the company lawyers ready to justify company legally approved procedures; the aircrew sweating bullets, praying that if they survive, there will be no ramifications – for they will have little help from the rest of the system, which was tucked up cosy, in plush offices, on great salaries paid for by the blood, sweat and tears of the poor bastards at the pointy end.

Don’t call Bollocks just yet – read the dribble from the ATSB then tell me that is the product of a system which cares about passenger safety. It certainly cares about protecting ‘the system’; but as an example of operational safety analysis – it stinks; again, another risible response to what could have been a very ugly situation. Yet the parade continues, companies afraid to rock the boat, aircrew being compliant, the system hobbling along on crutches, surviving on pure luck while those who should be making the changes to the ethos pat each other on the back, telling each other what a bloody great safety record we have.

Aye; lots of credit there for those who believe they matter so much more and deserve the self serving protection they have built into this flawed system. You know, if every Captain of every flight carried alternate fuel as a protest; there’s not a ducking thing anyone could do about it – watch the system change them – at lightning speed. Well: I can still dream; can’t I? Reminds me of an old Qantas yarn – a veteran skipper was hauled into the office one day – angry CP say “why have you always got 10 ton of fuel on board when you land?” The answer – a classic – “Well, I couldn’t get anymore on”.

Toot - Yes, I know – back to my knitting - toot.

RE: The search for investigative probity. - Peetwo - 07-24-2017

Aviation safety risk mitigation in the real world - Confused

Here is a simple exercise of 'real world' aviation safety vs our aviation safety adverse and AIOS inflicted Mandarins & minions.

From the ALPA Aviation Safety Forum... Wink

Quote:Aviation experts identify industry’s biggest safety challenges
Jul 21, 2017

[size=undefined]
ALPA aviation safety chair Steve Jangelis, TSB Canada chair Kathy Fox, NTSB acting chairman Robert Sumwalt.

National Transportation Safety Board (NTSB) acting chairman Robert Sumwalt said complacency is the biggest threat to safety the aviation industry. Speaking on a panel at the Air Line Pilots Association International Air Safety Forum July 20, Sumwalt said the issue is on the minds of NTSB investigators while conducting crash probes.

“Unanimously, we are well aware of that … we had several hull losses at my airline [US Airways] over a period of time and the management over the next few years were very aware of all of those things,” Sumwalt said. “But as time evolved, the people that were running the company weren’t the same people that were there during those bad times. We’ve had an excellent run of good, safe flights over the last number of years [but] the people leading the airlines … weren’t around back in those dark days. I worry about complacency in the industry overall.”

Sumwalt’s Canadian counterpart, Transportation Safety Board (TSB) of Canada chair Kathy Fox, said the biggest risk facing the industry is “trying to identify what your next biggest risk is.”

“There are still a lot of issues out there that we think are well known to the industry—unstable approaches that are contingent on landing, runway overruns, runway incursions—a lot more can be done to resolve those issues,” Fox said. “It will be a challenge … your next accident is in your data. The question is how we mine that data and find those risks.”

In a separate panel on threats to aircraft, ALPA unmanned aircraft systems (UAS) expert Jim Pala, described “the unbelievable growth in hobbyists of UAS” as the major safety threat to the industry.

“The internet is just littered with video of people who do not understand the risk that they’re subjecting airliners to, and where they’ll fly [their UAS],” Pala said. To mitigate the risk, Pala referred to FAA’s registration regulation, “and unfortunately that was just overturned in court, so that will have to be corrected at the next [FAA] reauthorization bill.”

Pala said FAA data on airliner sightings of UAS has tripled this year from 2016.

“There’s a UAS near-midair collision form on the FAA [Near Mid Air Collision System] website, so when you are flying out there and you do see a UAS please report it because we need the data,” Pala urged the audience of pilots.
[/size]
Mark Nensel

Quote:Mr Carmody : The evidence that I have over the last two years is, for example, 1,800 bird strikes in 2016, 1,700 bird strikes in 2015 and no reports of a drone striking an aircraft. But birds and other animals are striking aircraft. If I may, that is evidence. I have no evidence at the moment that the regulatory framework that we have in place—

CHAIR: Is that what you need, Mr Carmody? You need evidence? You want a drone to strike an aeroplane before you take some measures here?

Mr Carmody : You need to be able to make evidence based decision rather than hypothetical decisions. The evidence that I have from the United States is very clear. I have evidence from the United States about the effect of what is happening with drones in the United States....

Or at 05:10 here:

As a point of interest, we are all very much aware of Hoody's complete lack of transport safety investigation qualifications and chief executive experience. Not to mention the conflict of interest issues he has with his previous roles within ASA and CASA. Basically the minister's man is a walking, talking liability.

To put a cap on these obvious flaws in this minister's appointment of Hood as the Chief Commissioner at the ATSB, I thought it worth putting Hoody in amongst his international peers referenced in the short Aviation Week article above... Rolleyes

Quote:Kathy Fox

Appointed Chair of the Transportation Safety Board of Canada on 21 August 2014.
Appointed Member of the Transportation Safety Board of Canada in July 2007.

Kathy Fox selected air traffic control as a career in 1974, and worked at Transport Canada control towers in Baie-Comeau, Sept-Îles, Saint-Hubert and Montréal-Dorval, as well as at the Montréal Area Control Centre.

From 1982 until 1986 she was in charge of air traffic control training at the CEGEP Saint-Jean-sur- Richelieu, a cooperative training program coordinated by Transport Canada and the Quebec Ministry of Education.

Ms. Fox left operational controlling in 1992 to accept a developmental assignment with Air Traffic Services Headquarters in Ottawa, assuming progressively senior positions. She transferred to NAV CANADA in 1996 and became Director, Safety & Quality, in 1997; then Director, Air Traffic Services, in 1999. In 2000, she was appointed Assistant Vice-President, Air Traffic Services. She became Vice-President, Operations, on April 1, 2003.

As Vice-President, Operations, Ms. Fox was responsible for providing executive leadership and direction throughout NAV CANADA’s Operations Group. She retired from NAV CANADA in June 2007 and was appointed as a Member of the TSB in July 2007.

Ms. Fox received a Bachelor of Science degree and a Master’s degree in Business Administration from McGill University. She also completed a Master of Science in Human Factors and System Safety with Lund University in Sweden.

She has been extensively involved in other aviation activities for over 40 years, including sport parachuting and commercial aviation. She holds an airline transport pilot licence and flight instructor rating and has flown over 5000 hours. Ms. Fox is a recipient of the Fédération aéronautique internationale Paul Tissandier Diploma and the Queen Elizabeth II Anniversary Medal for her contributions to sport parachuting in Canada. She received the Transport Canada Aviation Safety Award in 1999. In November 2004, she was inducted into the Quebec Air and Space Hall of Fame. Ms. Fox received the Elsie MacGill Northern Lights Award in 2010 and the David Charles Abramson Flight Instructor Safety Award in 2011. She was also inducted into Canada’s Aviation Hall of Fame on June 9, 2016.

So a few parallels there but the depth of real world aviation experience and the academic quals of Ms Fox leave Hoody for dead. Not to mention there is very little evidence of COI issues in the impressive Ms Fox CV... Wink

Next from Mr Sumwalt's NTSB BIO:

Quote:

Page Content
Honorable Robert L. Sumwalt

Robert L. Sumwalt was appointed 37th Member of the National Transportation Safety Board (NTSB) in August 2006, whereupon President George W. Bush designated him as Vice Chairman of the Board for a 2-year term. In November 2011, President Barack Obama reappointed Mr. Sumwalt to an additional 5 year term as a Board Member. He was designated Vice Chairman by President Donald Trump on March 31, 2017.

Since joining the Board, Vice Chairman Sumwalt has been a fierce advocate for improving safety in all modes of transportation, focusing especially on teen driver safety, ending impaired driving, and eliminating distractions in transportation, as well as on several aviation and rail safety initiatives.

Before joining the NTSB, Mr. Sumwalt was a pilot for 32 years, including 24 years with Piedmont Airlines and US Airways. He accumulated over 14,000 flight hours. During his tenure at US Airways, he worked on a special assignment to the flight safety department, and also served on the airline’s Flight Operational Quality Assurance (FOQA) monitoring team. Following his airline career, Mr. Sumwalt managed the corporate aviation department for a Fortune 500 energy company.

In other notable accomplishments, Mr. Sumwalt chaired the Air Line Pilots Association’s Human Factors and Training Group, and co-founded the association’s critical incident response program. He also spent 8 years as a consultant to NASA’s Aviation Safety Reporting System (ASRS) and has written extensively on aviation safety matters.
Vice Chairman Sumwalt earned his undergraduate degree from the University of South Carolina and his Master of Aeronautical Science (with Distinction) from Embry-Riddle Aeronautical University, with concentrations in aviation/aerospace safety systems and human factors aviation systems.

# End of Official Bio #

Member Sumwalt has served as the Member on-scene for the following NTSB accident investigations:

May 2015 – derailment of Amtrak train 188 in Philadelphia, Pennsylvania

February 2015 – Metrolink commuter train struck a passenger truck and trailer fouling the track in Oxnard, CA

February 2015 – Grade crossing accident involving a Metro-North commuter train and a passenger vehicle near Valhalla, NY

December 2014 – Embraer Phenom 100 which crashed into a residential neighborhood in Gaithersburg, MD

September 2014 – Collision between a tractor trailer truck and mid-size bus near Davis, OK

March 2014 - Gas pipeline explosion in East Harlem, New York, which destroyed two apartment buildings and claimed several lives.

December 2013 - Collision of two BNSF freight trains resulting in explosion and fire of crude oil in Casselton, North Dakota

August 2013 - crash of a UPS Airbus A300-600 cargo jet on approach to Birmingham-Shuttlesworth International Airport in Birmingham, Alabama

May 2013 - highway grade crossing accident involving a trash truck and a CSX freight train in Rosedale, Maryland

May 2013 - collision of a Union Pacific freight train and a BNSF freight train, leading to collapse of highway bridge, near Chaffee, Missouri

February 2013 - crash of Hawker Beechcraft Premier 1A at Thompson, Georgia, that claimed five lives

January 2013 - allision of Passenger Ferry Seastreak Wallstreet with Pier 11 at Lower Manhattan, New York City

December 2012 - rupture and explosion of a natural gas pipeline in Sissonville, West Virginia

April, 2011 - Southwest Airlines B737-300 rapid decompression and emergency landing due to fuselage crack in Yuma, Arizona

September, 2010 - crash of a Freightliner Mid-Size tour bus on Interstate 270 in Bethesda, Maryland

July, 2010 - collision involving a barge and an amphibious passenger vessel in the Delaware River, near Philadelphia, Pennsylvania

May, 2010 - collision between the Staten Island Ferry Andrew J. Barberi and the St. George terminal pier in Staten Island, New York

September, 2009 - crash of an emergency medical services helicopter that claimed three lives in Georgetown, South Carolina; June, 2009 - derailment of a CN train which resulted in the explosion and burning of several ethanol tank cars at a grade crossing in Rockford, Illinois

December, 2008 - Continental Airlines flight 1404, a Boeing 737-500 that departed a runway during takeoff roll at the Denver International Airport, and caught fire

November, 2007 - collision between an Amtrak passenger train and a standing Norfolk Southern freight train in Chicago, Illinois

November, 2007 - rupture and explosion of a liquid propane pipeline in Carmichael, Mississippi

July, 2007 - crash of a twin-engine Cessna 310R airplane that impacted homes in a residential area in Sanford, Florida

October, 2006 - derailment of a Norfolk Southern train in New Brighton, Pennsylvania.

In addition, Sumwalt accompanied the NTSB's go-team to Lexington, Kentucky for the August 27, 2006, involving Comair flight 5191.

# # #

Since joining the Board, Member Sumwalt has served as the Chairman of the Board of Inquiry for the following NTSB public hearings and forums:

March 2015 – Trains and Trespassing: Ending Tragic Encounters

May 2011 - Truck and Bus Safety: A Decade of Progress

October 2010 – Fishing Vessel Safety Forum

February 2010 - collision of two Washington Metropolitan Area Transit Authority trains near Fort Totten Station, Washington, DC, on June 22, 2009;

June 2009 - landing of U.S. Airways flight 1549, Airbus A320, N106US, in the Hudson River, near Weehawken, New Jersey, on January 15, 2009;

February 2009 - safety of helicopter emergency medical services (HEMS) operations.

Not much to add to that... Wink

Except to say - does he want a job?

MTF...P2 Cool

RE: The search for investigative probity. - Peetwo - 08-01-2017

Singapore AAIB shows the rest of APAC how it should be done - Wink

Via Skybrary:

Quote:Description

On 12 July 2015, a Boeing 767-300ER (JA-606J) being operated by Japan Airlines on a scheduled passenger flight from Singapore Changi to Tokyo Haneda failed to follow its taxi clearance at night in normal ground visibility and attempted to take-off from a taxiway parallel to the departure runway. When ATC observed this, the controller instructed the aircraft to stop which was achieved without further event. After verifying with the flight crew that they could continue with the flight, it was re-cleared to taxi to the departure runway 20C via a new lit-centreline routing and the aircraft subsequently took off without further event.

Investigation

A Serious Incident Investigation was carried out by the Accident Investigation Bureau (AAIB) of the Singapore Ministry of Transport. By the time the Investigation began, CVR and FDR data had been overwritten but the QAR data retrieved by Japan Airlines was made available to the Investigation team.

It was established that the First Officer had been acting as PF and that both pilots had been in and out of Singapore four times. The Investigation did not note the overall or aircraft type flying experience of the two pilots involved or the Captain's time in command.

The PF pre-departure briefing included the taxi route he expected to get which involved arriving at the expected departure runway 20C via taxiways NC3 and EN (see the diagram below). When the clearance was actually given, it involved arriving via taxiway NC2, EP and EN.

In accordance with standard ATC operating procedures at night or in low visibility with a fully serviceable lit centreline control system available, the clearance was given as usual by switching on the lit centreline for the required route and instructing the aircraft to "taxi on the greens" - as three other departing aircraft had earlier done.

On transfer to the TWR controller, the crew confirmed that they were ready for take-off and were requested to expedite taxiing. As the aircraft continued taxiing on NC2 and passed taxiway A7, clearance to line up and take off on Runway 20C was given. The aircraft completed the right turn onto taxiway EP and the First Officer was reported to have called "runway heading check" which the Captain subsequently stated he had assumed meant that the First Officer "had verified that the aircraft was lined up on the runway in accordance with the take-off procedure in the Operator’s Aircraft Operating Manual". What this Manual actually required was found to be "before entering the departure runway, verify that the runway and runway entry point are correct”, and “verify that the airplane heading agrees with the assigned runway heading”.

Take-off was then commenced and the aircraft crossed the lit red stop bar on taxiway EP. The TWR controller observed what was happening and instructed the aircraft to stop which it did before reaching taxiway A3. This instruction was found to have been given prior to the commencement of a rejected take-off.

The maximum speed reached was not published.

Taxiway centreline lights (in green), deviation of aircraft (in red), and taxi route anticipated during briefing by the flight crew (in yellow) [reproduced from the Official Report]

During the course of a review of the sequence of events, the Investigation concluded in respect of the performance of the flight crew that:

Having attempted to guess the likely taxi route rather than more openly consider the possibilities, the First Officer "appeared to have fixated on this mental picture of taxi route (i.e. one single and gradual right turn to enter R20C)".

The First Officer "seemed to have been so fixated that he missed the red stop-bar lights on EP at the EP/E1 intersection and the fact that there were still green lights ahead for him to follow that would have guided him to turn left onto EN".

Neither pilot appeared to have noticed "the lack of runway lighting and markings (e.g. threshold and runway edge lights; runway designator, runway taxi-holding position markings) which identify a runway".

When pilots are instructed by the ATC to follow the greens, "they should still monitor the progress of the taxiing and ensure they know where they are on the taxi route" whereas in this Serious Incident, neither pilot appeared to "monitor the taxiing by, for example, cross-checking with the outside cues and aids, to ensure that they reach the correct runway entry point".

It appeared "that effective communication and coordination" between the two pilots "was lacking".

There was no evidence that the Captain was effectively fulfilling the role of PM during the taxiing of the aircraft.

It was noted that the airline involved used the LOSA process to monitor the day-to day performance of its flight crew.

The Investigation also considered ways in which the resilience of the current departure taxi procedures might be enhanced and concluded that:

In respect of taxi clearances, it was considered that there may be a case for "verbalising the specific taxi route" so that "any inconsistency between the verbalised taxi route and the taxi-on-the-greens route may also be spotted by flight crews, thus affording opportunities for clarification and correction".

In respect of take-off clearances, it was noted that these are "usually given to an aircraft when it is approaching the departure runway" on the rationale that at this stage "aircraft should be closely watched as they approach this position to ensure that they are taxiing to the correct runway before a take-off clearance is issued". It was considered that "it would be advisable not to issue line up and take-off clearances in one transmission" because separating them would give a controller "a chance to monitor the aircraft’s movement to ensure that it is on the right route to the departure runway" and introduce "another line of defence" against an aircraft crossing a clearly illuminated red stop bar as in this event.

In respect of the specific taxi clearance given in the investigated event, it was considered that "it would be prudent […] to issue the take-off clearance only after seeing that the aircraft has turned left from EP onto EN".

Safety Action taken as a result of the Serious Incident and notified to the Investigation included the following:

Japan Airlines introduced a new taxi procedure aimed at "preventing its flight crews from losing situational awareness during taxiing". This new procedure established the following rules, among others, for both pilots:
PF shall understand the ATC’s instructions and always control the aircraft with correct awareness of its position, using outside visual information (e.g. sign boards) primarily.

PM shall monitor the aircraft’s navigation, its present position and taxi route, and the ground speed with reference to charts or Airport Moving Map.

PM shall call out the name of next taxiway to turn, its turning direction, and its present ground speed before aircraft reaches the turn.

When instructed by the ATC to hold short of (a) runway holding point, hold line, or a taxiway, PM shall call out the position to hold and the present ground speed whenever PM has the hold position in sight.

PF shall stop the aircraft immediately whenever situational awareness of both PF and PM does not agree, or if any doubt is felt (e.g. when there is no callout from PM, even though approaching the taxiway to turn or the hold line to hold).

ATC Singapore subsequently classified the area where the incident took place as a 'hot spot' and promulgated this information accordingly. Watch Managers were also instructed to brief controllers to be "aware of the possibility of pilots mistaking a parallel taxiway as a runway, especially in situations when pilots need to taxi through a number of turns to reach the runway entry point" and "to consider separating line up clearance from take-off clearance".

One Safety Recommendation was made as a result of the Investigation as follows:

that Singapore Changi ATC consider verbalising the main taxi route in addition to the instruction to “taxi on the greens” in the taxi clearance. [R-2016-005]

The Final Report of the Investigation was published on 29 July 2016.

WOW! - 13 months from occurrence to a final report with a clearly defined systemic investigation leading to proactive safety actions and a safety recommendation issued without fear nor favour of offending the government agency addressee... Wink

MTF...P2

RE: The search for investigative probity. - Peetwo - 08-12-2017

Tassie Coroner is - "Not happy Greg" Dodgy

Via the Oz :

Quote:
Quote:Coroner slams “irrational” ATSB

2:58pmMATTHEW DENHOLM

A coroner has lambasted Australia’s transport safety investigator for its “irrational” refusal to provide witness statements.

A coroner has lambasted Australia’s transport safety investigator for its “irrational” refusal to provide witness statements to a coronial probe into a fatal plane crash.

Tasmanian Coroner Simon Cooper yesterday released the findings of his investigation into the deaths of two men in a light aircraft being used to take photographs of the 2014 Sydney to Hobart yacht race.

Mr Cooper’s report confirmed pilot error was involved in the crash, which claimed the lives of pilot Samuel Peter Langford and photographer Timothy Peter Jones, in Storm Bay, near Hobart, on December 29, 2014.

However, Mr Cooper’s report also raised questions about cooperation between coroners and the Australian Transport Safety Bureau.

Mr Cooper said he had directed Tasmania Police investigating the crash to provide the ATSB “with every assistance” for its own investigation, but that the bureau later refused to return the courtesy.

“The subsequent decision by the ATSB to refuse my request for copies of witness statements obtained in the course of its investigation was, in such circumstances, both surprising and disappointing,” Mr Cooper said.

“The ATSB made the obvious point in its reasons for refusal that ‘ATSB investigations and [C]oronial investigations/inquests [sic] fulfil separate statutory functions’.

“However, the common, and crucially important, statutory function of both the ATSB and the coroner is the investigation of fatalities with a view …to endeavouring where possible to prevent avoidable deaths occurring in similar circumstances in the future.”

Mr Cooper said he conducted his investigation into both deaths “on the basis that it was unnecessary to interview witnesses that had already been interviewed by the ATSB”.

“It was understood, wrongly it would appear, that the ATSB would provide copies of those statements to the Coronial Division,” Mr Cooper said. “The request for the statements was made after the ATSB had concluded its investigation and after it had released its report publicly.”

He said in refusing to provide the requested statements the ATSB relied upon section 60 of the federal Transport Safety Investigation Act 2003 (Cth), which prohibits the provision of restricted information, including ‘witness statements’.

“However, the prohibition is subject to section 60(5) which empowers the ATSB to issue a certificate authorising the release of witness statements where the ‘disclosure of the information is not likely to interfere with any investigation’,” Mr Cooper said.

“Despite this provision the ATSB still refused the request, when there was no rational impediment, at all, to the provision of the requested statements and its investigation was complete.”

Mr Cooper said both men died of multiple injuries sustained in the plane crash. He noted that the Cesna 172S aircraft had been flying well below the 150 feet minimum altitude set for low-level flying.

When the plane stalled there was insufficient altitude to recover. “The cause of the stall was pilot error,” he said.

The ATSB has so far not responded to a request for comment.

MTF...P2

RE: The search for investigative probity. - Cap'n Wannabe - 08-27-2017

At the request of P7...

(Insert photo of A380 simulator here..)

[Image: c700x420.jpg]

Quote:
Quote:ATSB push for simulator use
12:00amANNABEL HEPWORTH
ATSB says there is scope to widen the use of simulators for flight training exercises.

ATSB pushes for wider use of flight training simulators

The nation’s transport safety investigator has said there is scope to widen the use of simulators for flight training exercises.

Australian Transport Safety Bureau chief commissioner Greg Hood said the expanded use of simulators, coupled with rules that mandated the use of simulators in certain types of aircraft, had made flying safer.

“Simulator training reduces risk and the use of simulators positively contributes to aviation safety,” Mr Hood said. “The ATSB considers that the scope exists to further expand the use of simulators, particularly when training for abnormal operations.”

Respected Seattle-based aviation safety consultant Todd Curtis said training for emergencies continued to evolve.

“For the general question of, are there better ways to train emergency situations, that’s a constantly evolving issue,” Dr Curtis said. He said simulator availability could be an issue for some smaller aircraft.

Another safety expert said where simulators were not available, “the important thing is the instructor or examiner also understands what they are doing”.

The comments come as figures provided to The Australian showed there had been 25 incidents that involved simulated engine failures since the Transport Safety Act was put in place in 2003. This included 10 accidents and five serious incidents. Six of them were investigated. As the numbers were based on a keyword search of the ATSB database, it may not be definitive.

The nation’s aviation safety watchdog announced new requirements for training and checking exercises to be done using simulators in 2012.

This came after a serious incident at Western Australia’s Jundee airstrip in 2007 involving a mishandled go-around, which prompted the ATSB to note there was no mandated requirement for training in a simulator.

The issue came to a head again in 2010 after a fatal plane crash at Darwin that occurred shortly after takeoff on a training flight.

As well as reducing the risk of safety accidents and improving the fidelity of overall training, the rules were aimed at lowering wear and tear on an aircraft.

As well as the incident at Jundee, the Civil Aviation Safety Authority had pointed to cases where crew had lost control of aircraft while doing engine failure training exercises.

“When sophisticated flight simulators are used, the risks associated with conducting emergency and non-normal scenarios are completely removed,” CASA had argued at the time.

Under the rules, certain types of initial training should not be done in a plane that can seat more than nine people if an approved simulator is available in Australia. Also, certain training for a rating that applies to an aircraft that can seat more than 19 people or weighs more than 8618kg should be done in a simulator where an approved model is available in or outside Australia.

For certain recurrent training and checking, including certain exercises, operators of multi-engine aircraft seating between 10 and 19 people must use a simulator if it is available in Australia. Where the plane takes at least 20 people, a simulator must be used if one is available here or in certain other countries and certain activities are involved.

Mr Hood said the ATSB had welcomed the changes “and also acknowledges the wide adoption of simulation technology by the aviation industry to enhance the safety of flying generally and flying training more specifically”.

RE: The search for investigative probity. - Peetwo - 08-30-2017

Has Hoody finally lost the plot?

(08-27-2017, 09:33 AM)Cap\n Wannabe Wrote: At the request of P7...

(Insert photo of A380 simulator here..)

Quote:
Quote:ATSB push for simulator use
12:00amANNABEL HEPWORTH
ATSB says there is scope to widen the use of simulators for flight training exercises.

ATSB pushes for wider use of flight training simulators

The nation’s transport safety investigator has said there is scope to widen the use of simulators for flight training exercises.

Australian Transport Safety Bureau chief commissioner Greg Hood said the expanded use of simulators, coupled with rules that mandated the use of simulators in certain types of aircraft, had made flying safer.

“Simulator training reduces risk and the use of simulators positively contributes to aviation safety,” Mr Hood said. “The ATSB considers that the scope exists to further expand the use of simulators, particularly when training for abnormal operations.”

Respected Seattle-based aviation safety consultant Todd Curtis said training for emergencies continued to evolve.

“For the general question of, are there better ways to train emergency situations, that’s a constantly evolving issue,” Dr Curtis said. He said simulator availability could be an issue for some smaller aircraft.

Another safety expert said where simulators were not available, “the important thing is the instructor or examiner also understands what they are doing”.

The comments come as figures provided to The Australian showed there had been 25 incidents that involved simulated engine failures since the Transport Safety Act was put in place in 2003. This included 10 accidents and five serious incidents. Six of them were investigated. As the numbers were based on a keyword search of the ATSB database, it may not be definitive.

The nation’s aviation safety watchdog announced new requirements for training and checking exercises to be done using simulators in 2012.

This came after a serious incident at Western Australia’s Jundee airstrip in 2007 involving a mishandled go-around, which prompted the ATSB to note there was no mandated requirement for training in a simulator.

The issue came to a head again in 2010 after a fatal plane crash at Darwin that occurred shortly after takeoff on a training flight.

As well as reducing the risk of safety accidents and improving the fidelity of overall training, the rules were aimed at lowering wear and tear on an aircraft.

As well as the incident at Jundee, the Civil Aviation Safety Authority had pointed to cases where crew had lost control of aircraft while doing engine failure training exercises.

“When sophisticated flight simulators are used, the risks associated with conducting emergency and non-normal scenarios are completely removed,” CASA had argued at the time.

Under the rules, certain types of initial training should not be done in a plane that can seat more than nine people if an approved simulator is available in Australia. Also, certain training for a rating that applies to an aircraft that can seat more than 19 people or weighs more than 8618kg should be done in a simulator where an approved model is available in or outside Australia.

For certain recurrent training and checking, including certain exercises, operators of multi-engine aircraft seating between 10 and 19 people must use a simulator if it is available in Australia. Where the plane takes at least 20 people, a simulator must be used if one is available here or in certain other countries and certain activities are involved.

Mr Hood said the ATSB had welcomed the changes “and also acknowledges the wide adoption of simulation technology by the aviation industry to enhance the safety of flying generally and flying training more specifically”.

Why is Hoody trying to reignite interest in one of only a handful of safety recommendations that has been (supposedly) effectively addressed by the regulator the CASA... Huh

The disjointed, unbidden diatribe that has been coming out of the Chief Comissioner's mouth of late, was continued yesterday in the middle of the Senate Drone Inquiry public hearing:

Quoting my description for that bizarre short admission of incompetence by Hoody... Dodgy

Quote:Published on Aug 29, 2017

Yesterday in the Senate Drone inquiry public hearing Greg Hood indicated that the 1288 day old ATSB accident investigation, that saw a VARA ATR fly for five days and thirteen sectors with a structurally broken horizontal stabiliser, would shortly be producing a 3rd interim - WTD?

Ironically this quite obviously PC'd and Annex 13 compromised investigation was used as an example by Chief Commissioner Hood of how the ATSB, without fear nor favour, will pursue and highlight significant/critical safety issues when they are identified in the course of aviation accident/incident investigations - UDB!!

Nope IMO Hoody is off with the fairies... Confused

MTF...P2

Ps Here is the extended video which highlights why it was Hood felt compelled to give a un-official update to the ATR accident investigation... Wink

RE: The search for investigative probity. - Kharon - 08-31-2017

Things; to make you say Hmm.

Its quite remarkable how a ‘line’ or a statement gets picked up and breeds speculation. Especially when the ‘line’ jars with the general ebb and flow of discussion. Hoody’s little statement certainly has – the ‘Canary’ one, yesterday, at the committee hearing. Darts practice, just a few there, social and easy conversation, snippets, odds and sods, the usual aimless banter on such occasions. Them someone made a crack about the hi-viz Hood and his penchant for draping himself in fluro yellow motely.

“Well” says one wag – “he do seem to think he’s a canary; said so today at the ‘drone’ hearing”. (Ribald remarks deleted).

“He did say he would sing like one, even threatened to sing today” said another; “perhaps he will”.

That opened up a speculative debate; you can always tell when they get serious – the darts score reflects it; game on here thought I. Anyway – round and round it went for a half hour, touching the extremes of common knowledge and rekindling the speculation of how the man who signed off on the majority of the Pel-Air post accident embuggerance of James ended up running the ATSB. It remains, to this day, a great mystery to us all. I digress, but you get the drift; it always winds up the same way – how and why?

I toddled home, replaying the conversation (as you do) and decided to watch the ‘Canary’ scene in isolation, taking note of the words and music and body language. This I compared to a more relaxed Hood in ‘clips’ where he was well within his comfort zone. Current unsubstantiated gossip and speculation has Hood under the pump; now, if that is so; and, he is fighting for tenure then the ‘Canary’ and the thinly veiled venom quite visible through the little “we will sing” speech could be construed as an implied threat. As P2 points out – why drag up the unbelievable mess of the ATR incident during a discussion on ‘drones’.

Don’t know – beyond my pay grade – but it is, you’ll admit, an interesting little passage of play. Who knows? But, by golly, idle speculation and scurrilous gossip don’t half make the old curiosity bump itch.

Toot - toot.

RE: The search for investigative probity. - Peetwo - 09-01-2017

"..As P2 points out – why drag up the unbelievable mess of the ATR incident during a discussion on ‘drones’..."

And why rehash the identified safety issue that led to the reasonably successful safety recommendation, that saw CASA in 2012 mandating the use of simulators for certain high capacity airline/operator T&C/CAR 217 operations - see SR:AO-2007-017-SR-084:

Quote:Safety issue

There was no regulatory requirement for simulator training in Australia.

Action taken by the Civil Aviation Safety Authority

A summary of CASA activities to facilitate the use of full flight simulators and/or flight training devices follows:

The following inter-related activities are in the process of implementation:
•A combined workshop activity with Ansett Aviation Training, Capiteq Limited trading as AirNorth, Network Aviation Pty Ltd, Skippers Aviation Pty Ltd, PelAir Aviation Pty Ltd and CASA was held on 27, 28 April 2009.
•CASA has initiated a review of CAR 217 Training Organisations and Training Centres. This programme of review was prompted following investigations that revealed AOC holder training inconsistencies.
•A Component of the 'CAR 217 Training Organisations and Training Centres Special Emphasis Review' is to establish the level of company oversight and involvement with training and simulation, programmes that have been outsourced.
•Civil Aviation Order 40.2.1 - Instrument Rating, Section 12A, `Renewal using an overseas flight simulator training provider' has been added to include the option of instrument proficiency checks being conducted by an overseas simulator provider. This is to enable an instrument rating renewal where a specific type simulator is not available in Australia: -This amendment needs to read in conjunction with Advisory Circular AC 60-2 (1) of May 2007;
-The Advisory Circular identifies that CASA recognises the flight simulator qualifications certificates issued by Canada, Hong Kong (Special Administrative Region of China), New Zealand, the United States of America, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and the United Kingdom; and
-Civil Aviation Order 40.1.0 - Aircraft Endorsement - Aeroplanes, Section 6. This facilitates an option for instrument rating renewals to be associated with the issue of an aircraft type rating.

ATSB assessment of response/action

The activities undertaken by CASA appear to have facilitated increased use of simulators for endorsement and other training. However, the ATSB remains concerned that there is no regulatory requirement for simulator training when a suitable simulator is available in Australia.

Safety Recommendation

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue.

It is interesting to note that the serious incident that precipitated the issuing of the SR was a 'fuel starvation' occurrence at Jundee, WA in 2007: AO-2007-017

Quote:..The crew's endorsement and other training did not include simulator training and did not adequately prepare them for the event. There was no EMB-120 flight simulator facility in Australia and no Australian regulatory requirement for simulator training. In March 2009, an EMB-120 flight simulator came into operation in Melbourne, Vic. A workshop and discussion forum was conducted on 27 to 28 April 2009 for Australian Embraer 120 aircraft operators. All those operators were expected to commence utilising the simulator for flight crew endorsement training following that workshop...

Ultimately however, it was the tragic T&C accident involving an AirNorth Brasilia - see HERE - that forced the ATSB to issue the SR and consequently CASA to proactively address the safety issue.

It should be remembered with that particular accident there was some serious questions over why an experienced CASA approved T&C Captain would suddenly change/add an element to the prof/IRT check that he never, ever briefed or contemplated before. That element was the addition of a simulated (1 in a million) auto feather failure to the simulated V1 cut (EFATO).

MTF?- Definitely...P2 Cool

RE: The search for investigative probity. - Kharon - 09-22-2017

Finally.

At long last; someone on the UP actually see's why the ATSB, under Hood, is drowning in it's own excrement. The following post, from 'Compressor Stall' should be made poster size and nailed up on the wall of the ATSB dream factory walls - as a reality fix; it may remind 'em of what they are supposed to do.

Quote:Coincidentally I am currently on a course with a (foreign) pilot turned investigator who has worked on several high profile accidents that are well known to just about any pilot on the planet.

In discussion it would seem that the good and the bad human factors are to be integral to any report. Rereading this report tonight, it isn't the inclusion of the acknowledgement of the following of SOPs that now is of concern to me. It's the fact that the report has been released without any factual investigative information of the root cause of the event.

Quote:
however the examination was not completed in time for the release of this report.

Quote:
At the time of the release of this report, the reason for the lack of lubrication to the number four bearing had not been determined.

The crew's following of SOPs would normally have been drowned out in the investigation of the engine and other factors that actually caused the event. i.e. These detailed technical factors caused a situation which (incidentally) was well handled. The primary safety message would be in the reasons for the engine failure.

CS say's it all; summing up what every 'professional' worth the name thinks - neatly, succinctly and accurately. Tim Tam cupboard key delivered.

Selah.

RE: The search for investigative probity. - Peetwo - 09-22-2017

PC Hoody obfuscates reoccurrence trend vector - Confused

[Image: risk-impact-trending-charts-og-img.jpg]

Timely post "K"... Wink

- I also thought the following Centaurus comment worth regurgitating:

"..This writer has no problem with ATSB commending a pilot for superb flying skill in a serious situation. But not where everyone gets lots of kudos and hand claps like kindergarten kids simply for using SOP's..."

Although I notice the general message in that quote was predictively lost on the resident Pprune sycophant and CASA-sexual Lookie Loo... Rolleyes

However coming back to Hoody and the ATSB "drowning in it's own excrement"; I note that there is a couple of recent initiated ATSB AAIs of interest and intrigue that both have a déjà vu familiarity about them... Huh

Quote:Aircraft loading event involving Saab 340 VH-ZRB, Sydney Airport, NSW, on 14 September 2017

Investigation number: AO-2017-093
Investigation status: Active

Tab - Summary

Summary

The ATSB is investigating an aircraft loading event involving Saab 340, VH-ZRB, Sydney Airport, NSW on 14 September 2017.

During unloading at Wagga Wagga, ground crew detected 239 kg of freight was loaded and carried in error from Sydney. Retrospective calculations revealed that the aircraft was about 77 kg over the maximum take-off weight.

As part of the investigation, the ATSB will obtain relevant loading documentation, interview personnel involved in loading the aircraft and gather additional information.

Operational event involving B737, VH-VUE, 78 km ESE Adelaide Airport, SA on 13 September 2017

Investigation number: AO-2017-092
Investigation status: Active

Tab - Summary

Summary

The ATSB is investigating an operational event involving a Boeing 737, VH-VUE, on approach to Adelaide Airport South Australia, on 13 September 2017.

During descent, the airspeed trend vector started to increase. Control inputs made by the flight crew disconnected the autopilot and a minor airframe overspeed occurred. One cabin crew member sustained serious injuries and a second cabin crew member sustained minor injuries.

As part of the investigation, the ATSB will:

interview members of the aircraft crew and gather operational information

download and analyse data from the flight data and cockpit voice recorders

review air traffic control radar and audio recordings

review meteorological information.

Now it could be that both occurrences turn out to be non-events but their are some definite reoccurrence trends that in the normal course of an Annex 13 AAI investigation should at some point be examined. However given the list of reoccurrence events continues to grow seemingly unabated and without acknowledgement/recognition from the Hoody team, I won't be holding my breath... Dodgy

Way too early to say - & I guess it depends on how much the investigation is affected by political correctness - but this bit from the above summary...

"..During descent, the airspeed trend vector started to increase. Control inputs made by the flight crew disconnected the autopilot and a minor airframe overspeed occurred..."

...could possibly have the investigation identify some sort of 'automation complacency'. This provides me with an opportunity to regurgitate an excellent Harvard Business Review article that rehashes the AF447 disaster in the context of automation dependency/complacency... Wink

Quote:The Tragic Crash of Flight AF447 Shows the Unlikely but Catastrophic Consequences of Automation

Nick Oliver

Thomas Calvard

Kristina Potočnik

September 15, 2017

Executive Summary

The tragic crash of Air France 447 (AF447) in 2009 precipitated the aviation industry’s growing concern about “loss of control” incidents, and whether they’re linked to greater automation in the cockpit. As technology has become more sophisticated, it has taken over more and more functions previously performed by pilots, bringing huge improvements in aviation safety. But while overall air safety is improving, loss of control incidents are not. In fact, they are the most prevalent cause of fatalities in commercial aviation today, accounting for 43% of fatalities in 37 separate incidents.

Research examines how automation can limit pilots’ abilities to respond to such incidents, as becoming more dependent on technology can erode basic cognitive skills. The case reveals how automation may have unanticipated, catastrophic consequences that, while unlikely, can emerge in extreme conditions.

The tragic crash of Air France 447 (AF447) in 2009 sent shock waves around the world.

The loss was difficult to understand given the remarkable safety record of commercial aviation. How could a well-trained crew flying a modern airliner so abruptly lose control of their aircraft during a routine flight?

AF447 precipitated the aviation industry’s growing concern about such “loss of control” incidents, and whether they’re linked to greater automation in the cockpit. As technology has become more sophisticated, it has taken over more and more functions previously performed by pilots, bringing huge improvements in aviation safety. In 2016 the accident rate for major jets was just one major accident for every 2.56 million flights. But while overall air safety is improving, loss of control incidents are not. In fact, they are the most prevalent cause of fatalities in commercial aviation today, accounting for 43% of fatalities in 37 separate incidents between 2010 and 2014.

Loss of control typically occurs when pilots fail to recognize and correct a potentially dangerous situation, causing an aircraft to enter an unstable condition. Such incidents are typically triggered by unexpected, unusual events – often comprising multiple conditions that rarely occur together – that fall outside of the normal repertoire of pilot experience.

For example, this might be a combination of unusual meteorological conditions, ambiguous readings or behavior from the technology, and pilot inexperience – any one or two of which might be okay, but altogether they can overwhelm a crew. Safety scientists describe this as the “Swiss cheese” model of failure, when the holes in organizational defenses line up in ways that had not been foreseen. These incidents require rapid interpretation and responses, and it is here that things can go wrong.

Our research, recently published in Organization Science, examines how automation can limit pilots’ abilities to respond to such incidents, as becoming more dependent on technology can erode basic cognitive skills. By reviewing expert analyses of the disaster and analyzing data from AF447’s cockpit and flight data recorders, we found that AF447, and commercial aviation more generally, reveal how automation may have unanticipated, catastrophic consequences that, while unlikely, can emerge in extreme conditions.

Automation on the Flight Deck
Commercial aircraft fly on autopilot for much of the time. For most pilots, automation usually ensures that operations stay well within safe, predictable limits. Pilots spend much of their time managing and monitoring, rather than actively flying, their aircraft.
Cockpit automation, sometimes called the “glass cockpit”, comprises an ensemble of technologies that perform multiple functions. They gather information, process it, integrate it, and present it to pilots, often in simplified, stylized, and intuitive ways.

Through “fly-by-wire,” in which pilot actions serve as inputs to a flight control system that in turn determines the movements of the aircraft’s control surfaces, technology mediates the relationship between pilot action and aircraft response. This reduces the risk of human errors due to overload, fatigue, and fallibility, and prevents manoeuvers that might stress the airframe and endanger the aircraft.

Automation provides massive data-processing capacity and consistency of response. However, it can also interfere with pilots’ basic cycle of planning, doing, checking, and acting, which is fundamental to control and learning. If it results in less active monitoring and hands-on engagement, pilots’ situational awareness and capacity to improvise when faced with unexpected, unfamiliar events may decrease. This erosion may lie hidden until human intervention is required, for example when technology malfunctions or encounters conditions it doesn’t recognize and can’t process.

Imagine having to do some moderately complex arithmetic. Most of us could do this in our heads if we had to, but because we typically rely on technology like calculators and spreadsheets to do this, it might take us a while to call up the relevant mental processes and do it on our own. What if you were asked, without warning, to do this under stressful and time-critical conditions? The risk of error would be considerable.

This was the challenge that the crew of AF447 faced. But they also had to deal with certain “automation surprises,” such as technology behaving in ways that they did not understand or expect.

Loss of AF447
AF447 was three and a half hours into a night flight over the Atlantic. Transient icing of the speed sensors on the Airbus A330 caused inconsistent airspeed readings, which in turn led the flight computer to disconnect the autopilot and withdraw flight envelope protection, as it was programmed to do when faced with unreliable data. The startled pilots now had to fly the plane manually.

A string of messages appeared on a screen in front of the pilots, giving crucial information on the status of the aircraft. All that was required was for one pilot (Pierre-Cédric Bonin) to maintain the flight path manually while the other (David Robert) diagnosed the problem.

But Bonin’s attempts to stabilize the aircraft had precisely the opposite effect. This was probably due to a combination of being startled and inexperienced at manually flying at altitude, and having reduced automatic protection. At higher altitudes, the safe flight envelope is much more restricted than at lower altitudes, which is why pilots rarely hand-fly there. He attempted to correct a slight roll that occurred as the autopilot disconnected but over-corrected, causing the plane to roll sharply left and right several times as he moved his side stick from side to side. He also pulled back on the stick, causing the plane to climb steeply until it stalled and began to descend rapidly, almost in free-fall.

Neither Bonin nor Robert, nor the third crew member (Marc Dubois, the captain) who entered the cockpit 90 seconds into the episode, recognized that the aircraft had stalled despite multiple cues. In the confusion, Bonin misinterpreted the situation as meaning that the plane was flying too fast and actually reduced the thrust and moved to apply the speedbrakes – the opposite of what was required to recover from the stall. Robert overruled him and attempted to take control, but Bonin continued to try and fly the plane. He and Robert made simultaneous and contradictory inputs, without realizing that they were doing so. By the time the crew worked out what was going on, there was insufficient altitude left to recover, and AF447 crashed into the ocean, with the loss of all 228 passengers and crew.

The AF447 tragedy starkly reveals the interplay between sophisticated technology and its human counterparts. This began with the abrupt and unexpected handover of control to the pilots, one of whom, unused to hand flying at altitude, made a challenging situation much worse. A simulation exercise after the accident demonstrated that with no pilot inputs, AF447 would have remained at its cruise altitude following the autopilot disconnection.

With the onset of the stall, there were many cues about what was happening available to the pilots. But they were unable to assemble these cues into a valid interpretation, perhaps because they believed that a stall was impossible (since fly-by-wire technology would normally prevent pilots from causing a stall), or perhaps because the technology usually did most of the “assembling” of cues on their behalf.

The possibility that an aircraft could be in a stall without the crew realizing it was also apparently beyond what the aircraft system designers imagined. Features designed to help the pilots under normal circumstances now added to their problems. For example, to avoid the distractions of false alarms, the stall warning was designed to shut off when the forward airspeed fell below a certain speed, which it did as AF447 made its rapid descent. However, when the pilots twice made the correct recovery actions (putting the nose-down), the forward airspeed increased, causing the stall alarm to reactivate. All of this contributed to the pilots’ difficulty in grasping the nature of their plight. Seconds before impact, Bonin can be heard saying, “This can’t be true.”

Implications for Organizations
This idea – that the same technology that allows systems to be efficient and largely error-free also creates systemic vulnerabilities that result in occasional catastrophes – is termed “the paradox of almost totally safe systems.” This paradox has implications for technology deployment in many organizations, not only safety-critical ones.

One is the importance of managing handovers from machines to humans, something which went so wrong in AF447. As automation has increased in complexity and sophistication, so have the conditions under which such handovers are likely to occur. Is it reasonable to expect startled and possibly out-of-practice humans to be able to instantaneously diagnose and respond to problems that are complex enough to fool the technology? This issue will only become more pertinent as automation further pervades our lives, for example as autonomous vehicles are introduced to our roads.

Second, how can we capitalize on the benefits offered by technology while maintaining the cognitive capabilities necessary to handle exceptional situations? Pilots undergo intense training, with regular assessments, drills, and simulations, yet loss of control remains a source of concern. Following the AF447 disaster, the FAA urged airlines to encourage more hand-flying to prevent the erosion of basic piloting skills and this points to one avenue that others might follow. Regular, hands-on engagement and control builds and maintains system knowledge, enabling operators, managers, and others who oversee complex systems, to identify anomalies, diagnose unfamiliar situations, and respond quickly and appropriately. Structured problem-solving and improvement routines that prompt one to constantly interrogate our environment can also help with this.

Commercial aviation offers a fascinating window into automation, because the benefits, as well as the occasional risks, are so visible and dramatic. But everyone has their equivalent of autopilot, and the main idea extends to other environments: when automation keeps people completely safe almost all of the time, they are more likely to struggle to reengage when it abruptly withdraws its services.

Organizations must now consider the interplay of different types of risk. More automation reduces the risk of human errors, most of the time, as shown by aviation’s excellent and improving safety record. But automation also leads to the subtle erosion of cognitive abilities that may only manifest themselves in extreme and unusual situations. However, it would be short-sighted to simply roll back automation, say by insisting on more hand-flying, as that would increase the risk of human error again. Rather, organizations need to be aware of the vulnerabilities that automation can create and think more creatively about ways to patch them.

MTF...P2

RE: The search for investigative probity. - Peetwo - 09-29-2017

ATSB update on Mallard investigation - Confused

Via Oz Flying:

Quote:VH-CQA as it appeared at Ausfly in 2013. (Steve Hitchen)

Air Show Approvals under Scrutiny after Mallard Crash
29 September 2017

The Australian Transport Safety Bureau is looking closely at air show approvals following the fatal crash of a Grumman Mallard into the Swan River in Perth earlier this year.

Mallard VH-CQA was part of an air display on 26 January when it stalled mid turn and crashed into the water, killing both occupants.

In an update to the investigation issued last week, the ATSB said they could find no sign of pilot incapacity or defect in the aircraft that would account for the crash.

"The investigation has not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water," the ATSB stated in the update.

"Further analysis around the aircraft performance and operational factors, as well as the review of the planning, approval and oversight of the air display is ongoing."

During the investigation ATSB has examined the sequence of events leading up to the occurrence, aspects of the air display coordination, as well as the regulations, procedures and guidance relating to CASA-approved air displays, including:

approval process for the Perth Australia Day Sky Show going back several years and for other air display events across Australia

air displays applications from this and other events

CASA's Air Display Safety and Administrative Arrangements manual in use at the time and the revised version published earlier this month

surveillance and oversight of air displays as a whole

The ATSB has also examined the UK Air Accidents Investigation Branch report into the crash of Hawker Hunter G-BXFI at Shoreham in August 2015, which killed 11 bystanders.

The ATSB investigation is currently ongoing.

Read more at http://www.australianflying.com.au/latest/air-show-approvals-under-scrutiny-after-mallard-crash#YlWXQ1U1C1mCWfmj.99

Makes you wonder why they would discontinue this airshow/display related accident:

Quote:Collision with terrain involving Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, VH-GPT, Lismore Airport, NSW on 29 July 2017

Investigation number: AO-2017-077
Investigation status: Discontinued

Tab - Discontinued

Discontinued
Section 21 (2) of the Transport Safety Investigation Act 2003 (the Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 29 July 2017, the ATSB commenced an investigation into a collision with terrain involving a Zaklad Remontow I Produkeji Spreztu Lotnicz MDM-1P FOX-P glider, registered VH-GPT, at Lismore Airport, New South Wales.

The ATSB found that while conducting an aerobatic display, the glider impacted the ground heavily during the final manoeuvre. The pilot was seriously injured. Examination of the aircraft identified no mechanical issues or faults that may have contributed to the accident.

The Gliding Federation of Australia has conducted an investigation of this accident and the public report (S-1010) is availiable on their website.

The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements. The ATSB investigation AO-2017-013, Mallard aircraft, Perth, January 2017 is examining a range of issues associated with air shows, including the suitability of the regulations, approval and oversight of air shows, and compliance with regulatory approvals during air shows.

In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations. The ATSB assessed that no safety issues would be identified through further investigation. On that basis, the ATSB will discontinue this investigation.

Penny drops... Confused

Think I have just spotted the disconnection Big Grin

:
"..The ATSB has also reviewed the safety and administrative procedures necessary to conduct air shows and found that, in this case, preparations were consistent with regulatory requirements..." P2 - Think that should read "self-regulatory requirements.."

&..

"..In this case, the ATSB did not identify any organisational or systemic issues that contributed to the development of the accident or that might adversely affect the future safety of aviation operations..."
Hint Wink

[Image: Pollies_TW_2016_CB82A5C0-1576-11E6-99C802D27ADCA5FF.jpg]

MTF...P2

RE: The search for investigative probity. - Peetwo - 10-02-2017

ATSB fading into oblivion - Rolleyes

Over on the 'Accidents - Domestic' thread Cap'n Wannabe also picked up on the (above) Oz Flying article and an incident that occurred at Essendon Airport yesterday:

(10-01-2017, 06:22 PM)Cap\n Wannabe Wrote: Story with video here

Quote:Passengers scramble to safety after plane makes rough landing at airport
A plane has made a dramatic emergency landing after running into trouble above Essendon Fields in Melbourne this afternoon.

Emergency services responded to the runway about 6pm after reports the landing gear of the plane was not working.

The pilot was forced to burn off fuel for more than 15 minutes, according to the Metropolitan Fire Brigade (MFB)

The 9NEWS chopper camera captured the aircraft hitting the runway with force, with smoke seen coming from the wheels as it came to a stop.

All five people onboard were shown running from the door of the plane, with two girls hugging on the tarmac.

No one was injured in the incident.

More to come.

Quote:From Oz Aviation..

With both of these occurrences there is some interesting scuttlebutt and trivia that IMO highlights how the ATSB under Hoody continues to slide towards inevitable oblivion as an effective State (ICAO Annex 13) AAI.

Beginning with the Mallard investigation, I was under the misconception that the important update was disseminated by Hitch in the context of an ATSB media release. However after a brief search on the ATSB Newsroom and Social media it would appear that Hitch on his own initiative had diligently sourced the update from the investigation webpage:

Quote:Updated: 22 September 2017

On 26 January 2017, a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA, aerodynamically stalled and impacted water while participating in an air display, as part of the City of Perth Australia Day Skyworks event. The pilot and passenger were fatally injured.

This web update complements information already provided in the preliminary investigation report that was published on the ATSB website on 8 March 2017.

The investigation has not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water. Further analysis around the aircraft performance and operational factors, as well as the review of the planning, approval and oversight of the air display is ongoing.

During the investigation of the occurrence, the ATSB has examined the sequence of events leading up to the occurrence, aspects of the air display coordination, as well as the regulations, procedures and guidance relating to Civil Aviation Safety Authority (CASA)‑authorised air displays. This has included:

approval processes for several years of the Perth Australia Day Sky Show air display and for other air display events across Australia

the applications to conduct air displays, from this event and others across Australia

Air Display Safety and Administrative Arrangements manual (in use at the time of the occurrence) and the revised Air Display Administration and Procedure Manual (published September 2017). This manual provides guidance to CASA and the air display organiser

surveillance and oversight of air displays.

The ATSB has also examined the Aircraft Accident Report AAR 1/2017 – G-BXFI, 22 August 2015 that was published by the Air Accidents Investigation Branch United
Kingdom.[1] In summary:

At 1222 UTC (1322 BST) on 22 August 2015, Hawker Hunter G-BXFI crashed on to the A27, Shoreham Bypass, while performing at the Shoreham Airshow, fatally injuring eleven road users and bystanders. A further 13 people, including the pilot, sustained other injuries.

Preliminary analysis of this information has identified differences in the approval process within CASA, between civil and military (including combined) displays and between Australia and other countries. The ATSB is continuing to analyse this information, to determine whether there are any systemic safety issues in relation to authorised air displays.

The investigation is continuing.

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update.
-----
[1] AAIB reports can be viewed via www.gov.uk/aaib-reports

Note that the update occurred on the 22 September, the same date that the ATSB discontinued the 7 week AO-2017-077 investigation... Huh

With the Essendon incident yesterday the ATSB are yet to indicate whether they will be conducting an investigation into Australian registered B200 aircraft, VH-OWN.

Quote:ASN Wikibase Occurrence # 200056

Last updated: 1 October 2017
This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information. If you feel this information is incomplete or incorrect, you can submit corrected information.

Date:
01-OCT-2017
Time:
07:18Z
Type:

Beechcraft B200 King Air
Owner/operator:
Private
Registration:
VH-OWN
C/n / msn:
BB-936
Fatalities:
Fatalities: 0 / Occupants: 5
Other fatalities:
0
Airplane damage:
Substantial
Location:
Essendon Airport, Melbourne, VIC - Australia
Phase:
Landing
Nature:
Private
Departure airport:
Sunshine Coast Airport (MCY)
Destination airport:
Essendon Airport (MEB)
Narrative:
The aircraft sustained a partial landing gear collapse upon landing after the gear failed to lock-down. There were no injuries.

Sources:

http://www.9news.com.au/videos/cj88fnf26001x0gk0r6hlziwb/passengers-jump-out-of-plane-after-emergency-landing
http://www.9news.com.au/national/2017/10/01/18/13/plane-making-emergency-landing-in-melbourne-after-landing-gear-malfunction
________________________
https://www.flightradar24.com/data/aircraft/vh-own#f0f24db

Images:

If they do investigate I wonder if this is the first time that an incident aircraft will be involved in two active ATSB investigations at the same time?

Ironically this brings me to the next non-notified ATSB AAI update because apparently the other 'serious incident' investigation involving this aircraft was updated just last week - AO-2015-108 :

Quote:Updated: 27 September 2017

The draft report has been finalised and is currently undergoing an internal review process prior to approval by the ATSB Commission. Once complete, the draft report will be forwarded to relevant parties for comment prior to the completion and release of the final report.

It should also be remembered that AO-2015-108 occurrence involved the pilot that was tragically killed in the Essendon B200 DFO accident (Preliminary report AO-2017-024.). It is also rumoured that the DFO accident aircraft (VH-SCR) was the replacement aircraft for VH-OWN, which went U/S that tragic day... Angel

With the bizarre disconnect with the lack of dissemination of ATSB identified safety issues and information in active investigations, one wonders how hard it would be for the ATSB investigation updates to auto-notify on the accident investigation webpage index... Huh

MTF...P2

RE: The search for investigative probity. - Kharon - 10-06-2017

Another one bites the dust.

P2 – “With the bizarre disconnect with the lack of dissemination of ATSB identified safety issues and information in active investigations, one wonders how hard it would be for the ATSB investigation updates to auto-notify on the accident investigation webpage index"...

The ‘bizarre’ thing is that ATSB have not done a ‘performance’ analysis, drawn a profile and determined if there was enough airspace allocated to the Mallard flight. It is a simple analysis; speed v distance; turning radius required, minimum height and distance for final approach etc. If they have not the expertise to do this, then the pilot’s ‘mud-map’ calculations would assist. Shirley, CASA would have a copy. A simple sketch, showing that the aircraft needed a base turn @ 1000’ to arrive on a two mile final @ 700’ to allow for a minimum landing distance. That sort of thing would assist greatly. An analysis of the actual wind profile, weight, speed and distance parameters on the day (temperature corrected) would help.

If ATSB spent more time ‘investigating’ instead of dancing around the ministerial daisy patch and not upsetting CASA we may return to the good ol’ days, when we had a benefit from a world class accident investigator. That has to be better than using 500 pages to justify a CASA cock-up.

FWIW – I’ve run the numbers on the Mallard flight – ‘tight’ is an understatement; razors edge goes closer. But who’s going to own up to being part of a fatal accident; or, being reluctant to investigate it - properly?

Toot toot.