The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Peetwo - 10-12-2019

(10-11-2019, 11:18 AM)Peetwo Wrote:  ATSB World class? - My ASS!  


Ref: SBG, Senate Estimates thread, UP & Media reports.

https://auntypru.com/sbg-6-10-19-fuzzy-logic-redefined/ + https://auntypru.com/forum/showthread.ph…7#pid10667 + https://www.abc.net.au/news/2019-10-07/s…s/11578554 + https://www.news.com.au/national/breakin…b8e24d0597 + http://www.australianflying.com.au/latest/atsb-escapes-rrat-hearing-with-no-recommendations#F9rO68y7XhpPVyr8.99

(10-05-2019, 11:04 AM)Peetwo Wrote:  Angel Flight Inquiry report tabled - 

Well I'll be, this must be the world's quickest turn around on a Senate committee inquiry report since forever? Well at least since the Heff left the building...  

https://auntypru.com/wp-content/uploads/2019/10/report.pdf

Quote:List of Recommendations

Recommendation 1

1.74 The committee recommends that the Civil Aviation Safety Authority amend the Civil Aviation (Commercial Service Flights – Conditions on Flight Crew Licences) Instrument 2019 to remove the provisions for additional aeroplane maintenance requirements, which are beyond those required for airworthiness in the general aviation sector.

Recommendation 2

1.78 The committee recommends that the Civil Aviation Safety Authority amend the Civil Aviation (Commercial Service Flights – Conditions on Flight Crew Licences) Instrument 2019 to clarify what constitutes the 'operating crew' for a community service flight, particularly as this relates to additional pilots and mentoring arrangements.

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Also from the report it would appear that additional correspondence has been tabled and reviewed within the last week and a half which in the scheme of things is IMO significant:

Quote:1  Correspondence from Angel Flight, dated and received 29 September 2019, regarding a safety recommendation from the Australian Transport Safety Bureau.

(my bold)

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September 26, 2019


We have been requested by Angel Flight Australia to write to your committee, outlining our operation and the minimum requirements we demand for volunteer pilots flying for our organization. We operate in a similar fashion to Angel Flight Australia, and we assisted them in the setting up of that charity using our model.

All of our coordinated flights are under Part 95 category, and as such, there are no regulatory requirements imposed by the FAA other than the standard rules which apply to private flights in the USA. In 2012 the FAA published a set of recommendations; however, these were not enacted into law. We have chosen to adopt some of the recommendations: there are different rules for commercial operators who seek exemptions from the commercial rules, but these do not apply to us as we operate only under the private flight category.

To date we have undertaken 82,000 missions- defined as the passenger-carrying leg only (and approximately 140,000 flight sectors including the positioning and return flights). Although about 75% of our pilots hold instrument ratings, many of our flights are conducted under the VFR flight regulations. The climates in the Southwest US is similar to much of Australia, and VFR flight is suitable. Occasionally weather is bad enough to make conditions not suitable to fly under IFR.

The minimum standards we require are on the following page.

Sincerely,


Cheri Cimmarrusti
Associate Executive Director
Angel Flight West

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2  Correspondence to the committee from Angel Flight West (US), dated 26 September 2019, regarding its minimum standards for operation. Received 27 September 2019.

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ATSB SAFETY RECOMMENDATION


The Australian Transport Safety Bureau recommends that Angel Flight Australia
takes action to enable it to consider the safety benefits of using commercial flights
where they are available to transport its passengers.

ANGEL FLIGHT RESPONSE

Angel Flight has considered the recommendation carefully and has determined that
it maintain its current policy of giving priority to using private flights where possible
and to continue to use regular public transport flights when private flights are
cancelled or unavailable, and for transfers between capital cities.

The reasons for our decisions are:

Angel Flight rejects the claim in the ATSB report that, for Angel Flight
passenger carrying flights, the “fatal accident rate was more than seven
times higher per flight than other private flights” as invalid.

A valid analysis addressing passenger risks would require comparison of
passenger carrying Angel Flights and other passenger carrying private
flights. Since no such data are available for other private operations, the
only reasonable comparison is between all Angel Flight operations and all
other private operations. Even then, results must be treated cautiously
because an unknown proportion of private operations involve circuit
training and short local flying whereas all Angel Flight operations involve
flights with an average sector length of 1.5 hours.

The analysis in Table B2 on page 69 shows that, when all Angel Flight
sectors are included, the fatal accident rates are 0.5 and 0.2 per 10,000
flights for Angel Flight and other private flights respectively, and the
difference is not significant. Furthermore, when all accidents are included,
the rates are 1.1 and 1.5 per 10,000 flights for Angel Flight and other
private flights respectively.

Angel Flight rejects the claim in the ATSB report that “community service
flights conducted on behalf of Angel Flight Australia (Angel Flight) had
substantially more occurrences …… per flight than other private operations”
as invalid.

ATSB has compared Angel Flight operations, approximately 95% of which
operate to and from Class C and D airspace with other private operations
where an unknown, but undoubtedly much lower, proportion of flights are
in controlled airspace. Angel Flight has been unable to find any data that
would permit a valid comparison of similar operations for other private
flights.

The ATSB report acknowledges, in the Safety Summary, that “The types of
occurrences where flights organised by Angel Flight were statistically overrepresented
(as a rate per flight) compared to other private operations
were consistent with these operational differences.” However, the report
then immediately ignores the vastly different operating environments and
claims that the difference “indicated an elevated and different risk profile in
Angel Flight”.

Ps I note, that despite the AF response correspondence to the ATSB's SR being sent at least 1 week ago, there has been no corresponding update published on the ATSB website: https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-069/ao-2017-069-si-01/

I sometimes ponder whose side the Oz aviation editor Ironsider is on (the angels or the devil himself), especially after reading her take on the RRAT committee performance of the ATSB report :

Quote:Angel Flight ‘risk’ to remain on record

ROBYN IRONSIDE 



Investigators at the site of plane crash that killed 3 people near Mount Gambier. Picture: Tom Huntley

• 11:59AM OCTOBER 7, 2019
  

A report that found Angel Flight services posed a much greater risk to passengers than other private flights will remain on the public record, after a Senate committee refused calls to have it struck out.

Angel Flight, which pairs volunteer pilots with residents of ­regional and remote communities in need of transport to city medical appointments, had ­objected to the Australian Transport Safety Bureau report on a fatal crash at Mount Gambier in July 2017.

The triple fatality crash was the second involving an Angel Flight service in six years, and prompted a recommendation that the charity send passengers by commercial flights instead of with private pilots.

Chief executive Marjorie Pag­ani told the standing committee on rural and regional affairs and transport the ATSB report was “wrong, dishonest and misleading and used inventive and flawed datasets … It was, and it’s always been, set out to be an attack on this charity”.

Her demand for the report to be withdrawn was echoed by Aircraft Owners and Pilots Association executive director Benja­min Morgan, who claimed the report was designed to justify regulatory changes by the Civil Aviation Safety Authority targeting Angel Flight.

The committee’s final report said the work of the ATSB in accident investigation was “considered … to be world class”.

“The committee further appreciates that both the ATSB and CASA’s actions are aimed at ­improving safety and reducing risk,” the ­report said.

Two recommendations were made, for CASA to relax extra maintenance requirements for community service flights, and asking CASA to clarify what constituted an operating crew for a community service flight.

A CASA spokeswoman said: “We are … somewhat perplexed that a Senate inquiry into the performance of the ATSB somehow ­results in two recommendations for a completely separate organisation, CASA,” she said.

An ATSB spokesman noted it did not make any recommendations for the bureau.

Ms Pagani welcomed the two recommendations for CASA but said it was disappointing no further action would be taken with regard to the ATSB investigation.

"..said the work of the ATSB in accident investigation was “considered … to be world class”.


 
Hmm...does the committee expect industry professionals and subject matter experts to seriously not challenge such a bollocks statement?  

Example: https://auntypru.com/forum/showthread.php?tid=37&pid=10586#pid10586

Quote:..My point M’lud is a simple one. Why are both CASA and ATSB avoiding calling this accident for what it truly is and why, more to the point, have they generated phony statistics when across the globe, real data relating to a ‘loss of control’ in IMC are readily available. Australia has had it’s share of such accidents; that is where the real safety case lays – not in some confection of Angel Flight data. Ask for the real statistics – how many GA aircraft have been lost through this type of occurrence; and, how many of those were AF aircraft.  Then ask what ATSB and CASA have achieved in relation to a real reduction in the number of fatal accidents of this nature over the decades. The answer may just surprise you...

"..A report that found Angel Flight services posed a much greater risk to passengers than other private flights will remain on the public record, after a Senate committee refused calls to have it struck out.."

Personally I think there is something seriously dodgy going on when a senate committee does not insist that the ATSB either withdrawal and/or properly review an accident report that is so obviously consciously biased and deficient in the proper examination of the causal chain in the lead up to this tragic accident?

Perhaps the Leadsled comment off the UP goes to the heart of the issue of yet another ATSB final report aberration...

 

Quote:Originally Posted by Clearedtoreenter 

Quote:Hummm. The ATSB get off virtually scot free, although there were dubious statistics and glaring omissions regarding pilot qualification and behaviour and CASA get it in the neck from an inquiry that wasn’t even about them??? Hard to take anything too seriously in any of that!

Folks,

The ATSB treatment of "statistics" was a complete nonsense, as were certain subsequent statements emanating from CASA.

You simply cannot draw statistical conclusions from just two accidents over a longish period of time.

What has happened to Angel Flight reveals personal prejudices of some in ATSB and CASA, and little more.

Tootle pip!!

     

World Class - My Ass. (version II) 

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ref: https://auntypru.com/forum/showthread.php?tid=37&pid=10677#pid10677

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Read more at http://www.australianflying.com.au/the-last-minute-hitch/the-last-minute-hitch-11-october-2019#qw2hPvm2R6sX27mK.99

Yet there the DFO still sits... 

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RE: The search for investigative probity. - Peetwo - 10-30-2019

Latest from the 'Flight Safety Detectives' - 

It is extremely frustrating and internationally embarrassing but it would seem that we will continue to get bollocks topcover reports from the hooded Canary Annex 13 AAI charlatans, that start with the desired PC'd outcome and then manufacture/manipulate/obfuscate/doctor the findings to prove and enforce that outcome...

Meanwhile in the REAL WORLD of aviation accident investigation with the international counterparts to the ATSB are just getting on with the job of conducting without fear nor favour first class AAIs, sometimes without a tenth of the resources of the ATSB (eg see NTSC FL610 FR HERE).

In addition to that first rate report and for those interested in proper AAI analysis of the ongoing Boeing 737 MAX imbroglio, here is the latest from the World-renowned aviation-industry consultants and former NTSB investigators John Goglia and Greg Feith...

Quote:October 16, 2019

Cultural Differences in Airline Training, Experience and Decision-Making
Episode 6
Pilot training and confidence is [i]everything[/i] when it comes to safety in the air according to this week’s guest, Captain Chinar Shah. She’s a professional pilot, flying for more than 19 years,13 as a pilot in the airline ranks including a number of months in the Boeing 737 Max.  
 
Shah used to fly for Jet Airways in India. She converted her license in the U.S. with the FAA and she has seen all sides of training in the United States and worldwide. 
 
In this week’s episode, Shah and the Flight Safety Detectives talk about the training, confidence, knowledge, steel nerves and experience it takes to be the best of the best. According to Shah, pilots need to know what “The Normal” is in the air so when there is an extraordinary dangerous situation, the pilot knows immediately what is wrong and how to correct it.
 
She says, “The concern here is the [i]reaction[/i] to the malfunction, rather than the malfunction itself....You can’t have a complete power outage, for example, with only three minutes to land and not know what to do.”   
 
The culture of a country, the training and the airline may play a part in the way pilots react. Will a relatively new first officer with only 1,500 hours in the air comment on and help correct a mistake made in the cockpit by an experienced captain with more than 20,000 hours? She says, “There are times when I’ve seen people be completely submissive.”  
 
Shah has a deep respect for all of the professionals who inspect, repair and approve an aircraft before it takes to the air. She says, “I’ve always had great rapport with engineers and mechanics and they always teach you a thing or two about the airplane. Sure, it’s always the PIC (Pilot in Charge) who says whether the plane goes but it’s a collective decision.”
 
Shah started her flying in general aviation in India. She says that introduced her to a system she says might inhibit the growth of decision making skills because it is so restrictive. “[Overseas] they are very reluctant to let you go solo…In my opinion, that does hamper your growth as a pilot - your decision making.  In many parts of the world, you have someone telling you ‘do this, do that.’”

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Cultural Differences in Airline Training, Experience and Decision-Making
2019-10-16

Download

Plus: https://www.airlineratings.com/news/famous-crash-investigator-lashes-media-max-coverage/

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 11-08-2019

ATSB World Class? - My ASS: Version III  



Via LMH: 

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ATSB reinforces Recommendation in Letter to Angel Flight
7 November 2019
Comments 0 Comments
    

Read more at http://www.australianflying.com.au/latest/atsb-reinforces-recommendation-in-letter-to-angel-flight#3HcSGhGELvm9VPw3.99

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Hmm...sounds like the Hooded Canary is a bit miffed that Angel Flight is basically up yours to the bollocks safety recommendation his top cover organisation issued...  

I also wonder why it took him so long to respond remembering that AF issued their response (post [b]#282[/b] ) and made public on the Angel Flight Senate Inquiry web page over a month ago?? Probably wanted to keep it all hush...hush until  the bollocks Safeskies etc talk fests were over...

I also note a passing strange parallel disconnection when yesterday the ATSB issued the following media release in conjunction with the issuing of two preliminary investigation reports...

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Weather a focus of fatal accident investigations


Following the release of two preliminary investigation reports into multiple fatality accidents where the aircraft involved were operating under visual flight rules (VFR), the Australian Transport Safety Bureau (ATSB) is again highlighting to pilots the actions they can take to avoid a weather or low-visibility related accident.

Today, the ATSB has released the preliminary* reports for the collision with water of Bell UH-1H ‘Huey’ helicopter VH-UVC, and the collision with terrain of Mooney M20J VH-DJU.

Five people were killed in the accident involving VH-UVC, which impacted the ocean after last light at a time of reported severe weather near Anna Bay, NSW, on 6 September 2019. Then on 20 September 2019, a father and son died when VH-DJU collided with heavily-wooded terrain in the Dorrigo National Park near Coffs Harbour, NSW, in forecast weather conditions of low broken cloud.

Both accidents are unrelated, but in both instances the flights were operating under visual flight rules, and neither pilot had qualifications to operate in instrument meteorological conditions (IMC) or at night, the preliminary reports establish. Further, both investigations will continue to look at the weather and environmental conditions at the time of the accidents, among a number of other factors.

“It is important to stress that both investigations are still in their early stages, and the ATSB will not publish its findings until the final investigation reports are released,” said ATSB Executive Director Transport Safety Nat Nagy.

“But the ATSB notes that weather and environmental conditions are a focus for both investigations, and weather-related general aviation accidents remain one of the ATSB’s most significant causes for concern in aviation safety.

“Weather and low visibility-related accidents often have fatal outcomes, which is all the more tragic because they are almost always avoidable.”

To remind VFR pilots of the dangers of flying into IMC, and to highlight the actions they can take to avoid a weather-related accident, the ATSB is currently running a safety promotion campaign titled ‘Don’t push it, DON'T GO – Know your limits before flight’.

“‘Don’t push it, DON'T GO’ highlights three key messages: the importance of thorough pre-flight planning and having alternate plans, that pressing on where there is the possibility of entering IMC carries a significant risk of spatial disorientation, and the value of using a ‘personal minimums’ checklist to help manage flight risks,” Mr Nagy said.

“Pilots without a current instrument rating should always be prepared to amend and delay plans to fly due to poor or deteriorating weather and environmental conditions, and not to push on,” he said.

“Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather.

“Finally, setting expectations for your passengers beforehand can take the pressure off continuing with the flight if the conditions exceed your personal minimums.”


Source: ATSB
A total of 101 occurrences of VFR pilots inadvertently flying into IMC in Australian airspace were reported to the ATSB in the decade from 1 July 2009 to 30 June 2019. Of those occurrences, nine were accidents resulting in 21 deaths.

Findings from ATSB previous investigations into aircraft accidents where a VFR pilot flew into IMC makes for sobering reading. A selection of those findings are published in the ATSB’s recently updated Accidents involving pilots in Instrument Meteorological Conditions publication.

“The ATSB encourages VFR pilots to learn from the experiences of others, to help build a robust understanding of the risks of flying into IMC and just how rapidly such accidents can happen,” Mr Nagy said.

‘Don’t push it, DON'T GO’ follows on from a similar campaign the ATSB launched in 2018, titled ‘Don’t push it, LAND IT’, which was directed at helicopter pilots.

‘Don’t push it, LAND IT’ encouraged pilots to use their helicopter’s unique ability to make precautionary landings almost anywhere if faced with flying into IMC, fading day light or if something concerns them with their aircraft.

 “Know your limits before flight,” Mr Nagy said. “If you’re faced with deteriorating weather or if something just doesn’t feel right, don’t push it, make a precautionary landing. If you do decide to push on, it could be the beginning of an accident sequence.”

*Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report.

[b]Read the preliminary report AO-2019-050: Collision with water involving Bell UH-1H helicopter VH-UVC, 5 km south-west of Anna Bay, NSW, on 6 September 2019[/b]
[b]Read the preliminary report AO-2019-052: Collision with terrain involving Mooney M20J, VH-DJU, 26 km west of Coffs Harbour Airport, NSW, on 20 September 2019[/b]

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Funny thing about that MR is when you delve into the helpful Hooded Canary links you come across some even more bizarre passing strange dichotomies...

Exhibit 1 link:  Accidents involving pilots in Instrument Meteorological Conditions

Quote:In the decade from 1 July 2009 to 30 June 2019, 101 VFR into IMC occurrences in Australian airspace were reported to the ATSB. Of those, nine were accidents resulting in 21 fatalities. That is, about one in 10 VFR into IMC events result in a fatal outcome.

Exhibit 2 link: https://www.atsb.gov.au/publications/2005/pilot_behaviours_adverse_weather/

Quote:The work of this study is based on a set of 491 aviation accident and incident reports drawn from the Australian Transport Safety Bureau (ATSB) occurrence database. The study compares three groups of pilots who differed in their response to adverse weather conditions encountered during their flight...

Now refer to the PDF link provided - HERE - and go to the reference pages (57-58). All that decades of factual evidence, statistics and repeated findings and yet the Mount Gambier accident final report slates the blame on Angel Flight? - Yeah right...   

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 11-08-2019

(11-07-2019, 08:26 PM)P7_TOM Wrote:  Short, sharp and I hope to the point.

1969
1970
1971

In the USA this type of accident had become ‘less frequent’. In the USA one may gain an Instrument Flight rating in a fairly straight forward manner; the ‘rules’ for use of said rating are simple, cost effective and manageable. QED.  Less accidents with Visual pilots flying into instrument conditions.

The gaining of and ‘maintaining' instrument flight qualification in Australia are notably different.

Angel Flight is not a travel agent for scheduled services, never was, nor can it be – considering.

What have CASA and ATSB  actually done to prevent a regularly reoccurring accident type? (Bugger all would be the right answer).

I rest my case.

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RE: The search for investigative probity. - Peetwo - 11-19-2019

Is this finally one for the White Hats??

It may have taken nearly 3 years but today the ATSB finally released their report into the Perth Skyshow Mallard fatal (and not a Hooded Canary in sight...  ):

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ATSB calls for improved airshow display approval and oversight



[b]The ATSB is calling for the implementation of improved tools and guidance for airshow display approvals and oversight following its investigation into a high profile fatal accident at an Australia Day air display in Perth in 2017.[/b]

A pilot and passenger were fatally injured when their Grumman G-73 Mallard amphibious aircraft aerodynamically stalled over the Swan River and collided with the water during the air display, which was part of the City of Perth’s Australia Day Skyworks event.

The ATSB’s investigation into the accident established that the Mallard was to conduct two circuits over Perth Water, ‘in company’ (that is, following behind at a prescribed distance) with a Cessna Caravan aircraft. The pilot of the Caravan had previous experience operating in this location, including participating in this air display. Following the Caravan was intended as a risk mitigator against the Mallard pilot’s unfamiliarity with display flying over the Swan River.

However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.

The ATSB investigation found that the aircraft stalled at an unrecoverable height. Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft. Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.


“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.

“It is important that holders of these key positions have a thorough understanding of their role and responsibilities, to ensure adequate completion of safety critical tasks. Having well-defined, transparent, and consistent processes for planning and approval of air displays assists in identifying risks and implementing effective mitigation strategies.”

Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.

“Pilots should not undertake any impromptu manoeuvres that have not been planned or practiced,” he noted.

Since the accident, CASA had independently published a revised manual of guidance for air displays in September 2017.

“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”

Consequently, the ATSB has issued a formal safety recommendation to CASA calling for further improved air display approval and oversight tools and guidance, and enhanced procedures to ensure the suitability air display organisers, coordinators and participants.
More information about the accident, the investigation, and the safety issues and actions that have emerged can be found in the report AO-2017-013: Collision with water involving Grumman American Aviation Corp G-73, VH-CQA, 10 km WW of Perth Airport, Western Australia on 26 January 2017.

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This is the safety recommendation:

Quote:Air display approval and oversight

Issue number: AO 2017-013-SI-01
Who it affects: Air displays: Organisers and participants in air displays
Issue owner: Civil Aviation Safety Authority
Operation affected: Aviation: Other
Background: Investigation Report AO-2017-013
Date: 19 November 2019

Safety issue description
The Civil Aviation Safety Authority (CASA) did not have an effective framework to approve and oversight air displays, predominantly due to the following factors:

While the Air Display Manual provided guidance to organisers conducting an air display, it did not inherently provide the processes and tools needed for CASA to approve and oversee one and no other documented guidance existed.

Unlike the accreditation models adopted by some other countries, CASA did not have a systematic approach for assessing the suitability of those responsible for organising, coordinating and participating in air displays.

CASA did not have a structured process to ensure that risks were both identified and adequately treated.
The combination of these factors significantly increased the likelihood that safety risks associated with the conduct of the air display were not adequately managed.

Proactive Action

Action organisation: Civil Aviation Safety Authority
Action number: AO 2017-013-NSA-01
Date: 19 November 2019
Action status: Released
At the time of the occurrence, the Civil Aviation Safety Authority (CASA) had a revised air display guidance manual in draft. This was subsequently published in September 2017 as the Air Display Administration and Procedure Manual. Version 3.0 of this manual was published in April 2018. Pro-active safety actions arising from the new publication included:

the requirement to conduct a risk assessment as part of the air display planning
the requirement for the display organiser and display coordinator to document their relevant qualifications and associated display experience, to allow CASA to assess their suitability for the role
further clarification of roles and responsibilities, and display organisational expectations
enhanced forms for display pilots and additional crew, to assist the display coordinator in their assessment of the pilot and display, and to ensure all persons on board are identified and authorised.

ATSB response:
The ATSB acknowledges the improvements to the Civil Aviation Safety Authority’s Air Display Administration and Procedure Manual, and associated forms. While these changes improve existing guidance and partially address the safety issue, The ATSB considers that further improvements can be made to provide additional assurance of the suitability of key personnel, and to provide enhanced guidance and tools around the approval and oversight of air displays. Accordingly, the ATSB issues the following recommendation.

Recommendation

Action organisation: Civil Aviation Safety Authority
Action number: AO-2017-013-SR-029
Date: 19 November 2019
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to enhance their tools and guidance for air display approval and oversight, and procedures to ensure the suitability of those responsible for organising, coordinating and participating in air displays.

Current issue status: Safety action pending

Hmm...I can feel a running TAB coming on for when/where/if Fort Fumble will get around to proactively addressing this SR...

MTF...P2

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RE: The search for investigative probity. - Kharon - 11-20-2019

Good catch ATSB

“However, after conducting two passes in company, with both aircraft departing the display area, the pilot of the Mallard subsequently requested of, and received approval from, the air display ‘ringmaster’ to conduct a third pass. The aircraft then returned to the display area without the Caravan and in a manner contrary to the standard inbound procedure, requiring turns at higher bank angles and lower altitudes within a confined area to become established on the display path.”


It is good to have a puzzle solved. It was always suspected that there was not enough ‘space’ (height, time and distance) allowed for the manoeuvre; always looked ‘cramped’ and indeed needing ‘higher bank’ at low levels to fit.

“Had the Mallard re-entered the display area using the standard procedure for the air display, the manoeuvres required to position for the third pass would have been relatively benign with a significantly reduced risk of mishandling the aircraft.”

There was a suspicion that the pattern flown was a ‘requirement’ - good to see that ruled out, fairly and reasonably.

“Further, the pilot’s decision to carry a passenger was also contrary to the requirements of the display approval and increased the severity of the outcome.”

There’s not too much CASA or ATSB can do about ‘attitude’ or ‘professionalism’; display flying is a discipline, not a Sunday pre lunch ‘jolly’. The air show accident statistics back up the need for both. 

“Air displays have inherent and unique risks that everyone involved – pilots, organisers, and regulators – have responsibilities in addressing,” ATSB Executive Director Transport Safety Nat Nagy said.

Mr Nagy said the investigation also highlighted that pilots can limit their exposure to risk by only participating in displays that are within their own and their aircraft’s capabilities and limitations.

Spot on.

“The ATSB acknowledges the improvements to CASA’s manual of guidance for air displays and the associated forms,” Mr Nagy said. “But while these changes improve existing guidance, we consider that they only partially address the safety issue surrounding air display approval and oversight.”

In CASA’s defence – there is not too much more they could have done, than they did to prevent this accident. No amount of paperwork, improved or otherwise could have changed the outcome. A poorly flown pattern, low, slow, steep turns close in and tight? Tricky stuff. Had the pilot mentioned his true intentions to CASA, I reckon they may have had somewhat to say about the notion like – “just leave your licence on the desk”.  As I remember it, there was some discussion about ‘experience on type’ and a bit of push and shove for the approval to operate being issued. (P2 – was that an Estimates thing?). Tough on the Regulator – miserable bastards for a Nay; in the gun for a Yeah. They gave the benefit of doubt – and end up having to provide more ‘paper-work’ and more restrictions. Sometimes, (rarely) I feel a modicum of sympathy for the CASA crew at the coal face. Tough call for CASA, decision made with the best of intentions, within the rules; can’t blame ‘em for the result (IMO).


Sad event, nicely done ATSB,

Toot – toot.

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RE: The search for investigative probity. - P7_TOM - 11-20-2019

Not a fan – Nope: not at all.

However;.... given ALL the facts, Instagramas etc. (WTD that may be) included, plus some ‘other’ information; there is credit for Nagy in this report. There is even the whisper of support for CASA (believe it or not).

We must hope, that for once, CASA actually do the usual and step neatly around the ‘recommendations’. There may be, (expert opinion lacking) a need to tidy up some of the rules which govern ‘Air-Shows’ but, on the whole, the management of those in Oz have, so far, kept things safe and tidy with tolerance, understanding and tacit latitude. So the need for ‘more’ restrictions is debatable.

Just say there has been 1000 perfectly safe, well managed, properly flown, compliant sorties over the last five years – (for a number). Of those, there has been one operated outside the prescribed ‘envelope’. So why should the compliant rest suffer additional restrictions for being good kids?

It ain’t fair. One silly sod takes off into IFR; so 50 odd 'compliant' - sensible pilots must cop the penalty? The number of accidents – compared to the number of safe arrivals is very low; so why do those who do ‘the right thing’ cop a penalty or restriction, because an individual thought dancing to his own music would be OK.

Most of us try, hard, to always be within the boundaries of ‘compliance; be it air show rules, IFR rules or VFR rules, all of which were produced as a response to a ‘minority’ aberration, not the majority of law abiding citizens.

As said, not an ATSB fan – but job well done; this time the ‘existing’ discretionary system works; all things considered. There was a little more to this one than meets the eye.


Cheers.

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RE: The search for investigative probity. - Peetwo - 05-20-2020

Dick pitches in on Mangalore midair -

Ref from ATSB delays:

(04-24-2020, 10:16 AM)Peetwo Wrote:  Hooded Canary releases Mangalore mid-air prelim report - 

Via HC central yesterday:

Warning: Bucket may be required for the Hooded Canary segments -   

Quote:Read the preliminary report AO-2020-012: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel Air, VH-AEM, near Mangalore, Victoria, on 19 February 2020

Not sure exactly why the Hooded Canary feels the need to put his 2 bob's worth in? Why can't he just leave it to his experts? Perhaps HC is just trying to justify his existence and bloated (nearly 500k) base salary but I do wonder if there isn't some hidden (singing Canary) message behind this?

For a more damning assessment of the ATSB's findings so far IMO you can't go past the 'Advance' post off the UP -   

Quote:  US vs Australian airspace

---

In the USA ALL IFR aircraft are separated by ATC.

Dick Smith has been trying to bring Australian safety standards up for at least 30 years by insisting on the same ATC separation here.
The ATSB report confirms what this forum has known for some time => both aircraft were visible to ATC via ADS-B tracking.
Airservices have a flow chart that demonstrates the workload of providing separation is LESS than the workload of only providing traffic.
WHY?
Each task requires ATC considering the trajectory of every aircraft in the sector.

To separate aircraft, the ATC makes a decision and issues an instruction.

If the ATC passes traffic then the pilot may respond with his decision to change altitude or track or otherwise avoid the conflict.

BUT then the ATC has to assess this change to determine if a different conflict will occur and perhaps pass further traffic.

So let us stop accepting the nonsense argument that it costs more to provide separation compared to traffic information - it does not.

What is the total cost of this accident going to be?

Almost two decades ago Dick organised a trip by both Airservices and CASA staff to the United States with flights arranged to demonstrate the ease of use and safety of Class E airspace.

A very experienced US ATC from the Southern California Terminal Radar Control Unit addressed the team and pointed out how easy it was to provide separation and how safe the result.

John and Martha King of King schools tried very hard to educate the team on why US airspace is as safe as Australian airspace in terms of collisions per flight hour but has so much greater traffic density and thus greater actual safety.

A lot of very experienced pilots and controllers in this country know Dick was right back then and he is proven right again by this accident.

CAN WE LEARN FROM IT THIS TIME???

(04-27-2020, 09:55 PM)Kharon Wrote:  (PWP and cranky).

The 'accidents' we had to have.

A Pipistrel crashed and burned; quite recently. One killed, one badly mauled by the old enemy – fire. Now the culprit is alleged 'engine failure' – an accident happened. Could have been any engine on any aircraft. An unpredictable occurrence, part of the risk matrix, bus, truck, car and even lawn mower motors occasionally quit – without notice – results directly in relation and proportionate to circumstances. Unavoidable.

But what of those accidents which were clearly and inexcusably preventable? How do we come to terms with those? Essendon – entirely preventable. The bloody DFO building should never, not ever been allowed. Six dead, with a potential for many, many more.  And yet?

Now four dead in an entirely preventable mid-air collision -

Old Akro (legend) "By definition, IFR aircraft can not separate themselves visually and giving them traffic does NOT solve the problem. IFR aircraft are frequently constrained to fly one flight path and one only - they have no choice; consider an instrument approach for example."

Advance (Choc frog candidate) - “Get on to Worksafe, the Victorian Police, the AFP, your local MPs and point out that the Airservices organisation responsible for separating aircraft had the means to do so but did not; that the CASA OAR organisation charged with implementing international best practice in airspace administration has failed to do so.

Thing that really bunches my panties is the incredible difference in the 'take' between the highway death of four Coppers and the mid air collision between two aircraft. Same ducking body count. The world, his wife and every bleeding heart halfwit on morning TV is wittering on about an explainable road accident, of which we have many. Yet non of these talking heads seem to be in the slightest concerned that a major infrastructure, aircraft separation system has a gaping hole in it; several holes in fact. An allegedly 'fail safe' public transport system has failed four pilots.  No one apart from the responsible ATCO' (bless 'em) and those few remaining flying public transport aircraft, within that deeply flawed monopoly system seem to give a toss that this event occurred despite many, many warnings, issued by experts to several governments that Australia has got airspace wrong.

Four Bobbies killed in the line of duty – a national outpouring, gnashing of teeth and much wailing; furry muff. BUT. Four dead in a mid-air – page three for 12 hours and forgotten. In this day and age of whiz-bang technology the mid air collision should never have been even a remote possibility – and yet, there it is. Done, dusted and waiting down the three years required for ATSB to eventually finish smoothing it all away, under the ever hungry bipartisan carpet.

Will these accidents spur government to come to grips with real 'air safety'? No reason it should – it never has in the past, despite millions spent on gaining the right answers –only  to be obfuscated, manipulated and diluted to a fare thee well. Sickening waste.

Shame, shame on the lot of ya. Disgusting don't cover it, but 'twill suffice for now.

Toot – Aye, Full steam – Toot.

Via Skynews:

Quote:

'We are flying blind': Dick Smith calls for urgent air safety reforms after fatal mid-air collision
18/05/2020|6min

Former head of the Civil Aviation Safety Authority Dick Smith is calling for the reform of Australia’s air traffic control regulations, following the fatal mid-air collision of two planes at Mangalore in February which killed four people.

Most airports, excluding those in major cities and regional areas, operate in uncontrolled airspace where the responsibility for aircraft to communicate is left to the pilots.

Mr Smith told Sky News “you’re absolutely flying blind up there” and more crashes are likely to occur unless changes are made.

Former US Airforce pilot Richard Woodward was commissioned by the Howard government 20 years prior to reform the country’s low level airspace, but was unable to complete the task due to costs and sector complacency.

Mr Smith’s most recent attempt to prevent introduce safety regulations was brushed off by Deputy Prime Minster Michael McCormack last year, who saw no cause to review Australia’s air traffic regulations and was backed by Centre Alliance Senator Rex Patrick.

“We’ve operated across Australia for decades without controlled airspace at these airports and we’ve had very few accidents and what I don’t want to see happen is we burden the industry with additional costs, particularly when general aviation is in fact a struggling industry,” Mr Patrick told Sky News.

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 09-12-2020

(09-05-2020, 10:57 AM)Peetwo Wrote:  Chalk & cheese, plus the Ghost Who Walks is back?? 

I note that through the week that the ATSB prelim report into the tragic Broome R44 inflight breakup accident was released -   : 



Ref: https://www.atsb.gov.au/publications/investigation_reports/2020/aair/ao-2020-033/

I also note that the 'Ghost who walks and talks beyond Reason' is back and has been promoted, at least for this week, to the seemingly ever changing executive position of 'ATSB Director of Transport Safety'...  : https://www.atsb.gov.au/media/news-items/2020/r44-helicopter-in-flight-breakup/

  
  Hmm...the Hooded Canary must be really scraping the bottom of Lake Burley Griffin if the best he can put up for Transport Director?? Remember this was the dude that brought us this load of codswallop: 



And who could forget this insult to our collective intelligence and PelAir survivors Kaz Casey and Dom James: The hidden agenda of PelAir MKII IIC Dr Walker



The Chalk: Regardless of the return of the 'Ghost Who Walks', the efforts of the IIC and his investigative team in compiling a factual and concise prelim report without any apparent political and bureaucratic influence, spin and bulldust is refreshing -    
The Cheese: Which is in stark contrast to the topcover snowjob that appears to be occurring with the, fast approaching, 3 year  ATSB investigation into the Essendon DFO approval process, which (without any public notification) was recently updated (14 August 2020) with yet another delay to the anticipated completion date: 
  

Quote:  Anticipated completion: 3rd Quarter 2020  

Hmm..no comment required - 

Speaking of 'chalk and cheese' I note that the Flight Safety Detectives, John Goglia and Greg Feith have been busy putting out yet more fascinating, informative podcasts on the how, what and why of professional tin-kicking under the auspices of the US NTSB.

   
Episodes of interest and relevance (the NTSB chalk to the ATSB cheese):

---

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The Discipline Needed for Aviation Safety
2020-08-12

Episode 33

Flight Safety Detectives listeners ask for insider details and John and Greg deliver! A theme in this wide-ranging discussion of questions received is the importance of discipline.
 
A listener asked for the backstory in the NTSB investigation of Eastern Airlines Flight 980. Greg shares the details of the Jan. 1, 1985 crash and the 10 months of effort that led to him climbing a mountain in search of the cockpit and flight data recorders. That crash, in part, was caused by the air check pilot not following procedures.
 
Another question related to 2011 crash of a Cessna 421. That accident illustrated the insidiously damaging effects of lightning strikes. John and Greg discuss errors in the NTSB accident report. A lack of a disciplined look into the engine damage missed the true cause.
 
The discussion discipline in all areas of aviation then turns to a series of accidents involving Mooney aircraft. Greg has again and again found fuel tank drain holes mistakenly plugged by sealant during repairs of other issues. This lack of care in maintenance leads to water in the fuel and disastrous results.



The Cost of Flight Safety
2020-07-07

Episode 29


Flight Safety Detectives Greg Feith and John Goglia look at the many costs associated with flight safety. Costs include dollars and lives.

July is proving to be a deadly month in the skies. In the first 7 days there were 7 fatal accidents, several with multiple fatalities. As investigations begin, John and Greg look at common potential factors like weather, mechanical issues, fuel supply and more.

They shed light on a new factor – COVID-19. Many pilots have been grounded during the pandemic. Pilots need to “get back in the books” to maintain flight skills. They need to recommit to the checklists that are designed to ensure safe operations.

John and Greg discuss how airlines and pilots often avoid acting on airworthiness directives (ADs) and service bulletins because of the time and cost involved. They share many illustrations of the larger costs of crashes and loss of lives.




You Asked, Flight Safety Detectives Answer
2020-06-17

Episode 28

Flight Safety Detectives Greg Feith and John Goglia answer listener questions in this lively episode that shares details of air crash investigations. Get a rare look inside the NTSB command center and on-scene investigations.

 

• The NTSB bell rings signaling an air crash. What’s next?
  
  
• How does a systemic investigation happen amid the chaos of an accident scene?
  
  
• What are the qualifications of investigation teams?
  
  
• Who decides on the content of accident reports?
  

 
Hear about Greg’s bumpy ride to Guam, how John got in trouble while working at USAir, and more!

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MTF...P2 

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RE: The search for investigative probity. - Peetwo - 02-02-2022

Angus's 'search for investigative probity'?? - 

After this performance...


...beef patty Angus is IMO in much need of an image and credibility reset - 

Perhaps the outcome of the consultation on the proposed amendments will provide an opportunity for CC Angus Mitchell to get that reset??

Via the ATSB: 

---

ATSB opens consultation for reporting legislation update



New categories of aircraft operations, additional responsible persons, and harmonised definitions with domestic and international standards are drafted in proposed updates to Australia’s Transport Safety Investigation Regulations.

The ATSB is calling on its aviation, marine and rail stakeholders to take part in the consultation process to help shape the next update of Australia's Transport Safety Investigation (TSI) legislation.

Under the TSI Act, The TSI Regulations define what occurrences are reportable to the ATSB, how urgently they should be reported, what form a report must take, and who is responsible for making a report.

The ATSB has released an Exposure Draft and Consultation Paper detailing proposed amendments. This is towards finalising the new Regulations by mid-2022, for commencement at the start of 2023. 

The proposed changes have been prepared by the ATSB working closely with the Office of Parliamentary Counsel, and have been shaped by the ATSB’s ongoing work, a series of past consultations in 2019 and 2021, and continuous engagement with industry stakeholders.

“Broadly speaking, the proposed changes aim to bring transport safety investigation legislation in line with industry and international standards, and help the ATSB maximise its ability to improve transport safety, without placing undue burden on industry,” ATSB Chief Commissioner Angus Mitchell said.

Among the six issues discussed in the Consultation Paper is the proposed recategorisation of aircraft operations, to prioritise them in four distinct categories.

New, clear definitions for aircraft accidents and incidents would then prescribe what occurrences need to be immediately reported, or routinely reported, for each category of operation, with higher categorisations bearing a stricter reporting standard.
“The Statement of Expectations, provided to the ATSB by the Minister, makes it clear we should use our resources for the greatest public safety benefit,” Mr Mitchell said. 

“Ensuring the greatest focus is on receiving reports with the highest potential to improve safety, is in line with that directive.”
The proposed changes would also extend the persons who are responsible to report occurrences in the aviation and marine sectors.

In aviation, this would include sport aviation bodies and insurers of aircraft as responsible persons. In marine, pilotage providers and vessel traffic service authorities would be added.

“It’s important to note that, as with the existing framework, a responsible person only has to report an occurrence if they have a reasonable belief that no other responsible person has reported the matter,” Mr Mitchell noted.

“For example, if an aircraft is damaged in an incident, and the insurer receives assurance from the pilot that the occurrence has been reported, the insurer would not have to report that incident.

“But the goal of this change is to make sure that accountability is there, and ultimately reduce the number of occurrences that are not reported to the ATSB.”

One welcome proposal for all operators will be the extension of written reporting timeframes from within 72 hours to within 7 days. This will form part of a separate package of work to amend the TSI Act.

“This proposal relates to the written report, which follows the initial notification via telephone as soon as possible after an occurrence,” Mr Mitchell explained.

“Considering prior consultation and stakeholder engagement, the ATSB is of the view that a 7-day window to file a formal written report will maximise the quality of information that can be included, without sacrificing the recency necessary to ensure the information is current. If this proposal is supported by industry, we will work with government on making these changes.”

The Consultation Paper also explains a number of clarifications, minor and technical changes, proposed with the goal of better aligning the language of legislation to the other changes proposed in this consultation round. 

It also proposes prescribing the format for written reports, aligning with the Minister's Statement of Expectations by ensuring the ATSB can work efficiently to improve transport safety.

“I encourage all of our stakeholders to go to our website and check out the Consultation Paper and Exposure Draft for these proposed changes,” Mr Mitchell concluded.

“You can then take part in our consultation survey and give us the valuable feedback we need to finalise these changes.”
Review the Consultation Paper and other documents here.

Complete the consultation survey here.

Links: https://www.surveymonkey.com/r/ATSB_new_TSI_regs_consultation & https://www.atsb.gov.au/public-consultation/new-tsi-regulations/amendment-to-the-transport-safety-investigation-regulations-2021/

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Read, absorb and get involved/provide feedback -   

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 02-27-2022

Bearded Popinjay's search for investigative probity; or self-flagellation via Social Media??

Via the AOPA thread:

(02-20-2022, 08:09 AM)P7_TOM Wrote:  The Morgan ensemble de jour; in technicolor.

Having sat through some 35 minutes of watching the Morgan shirt front, a couple of points made deserve some attention. Mind you, I would have really liked to see what is going at YSBK - alas, the change of scene morphed into a stunning view of the Morgan shorts. Say no more.

Point one: ATSB. I note that the bearded popinjay now running the shop has made a splash (no pun intended) by buying into the MH 370 debacle, strangely coincidental with the expected Sky News version shortly to be aired. Passing strange is that; time money, resources and effort spent on highlighting one of the most scandalous episodes in the ATSB history. Many of the outstanding questions still remain unanswered. That aside - how come the serious delays in reports on critical accidents, like the mid-air collision, or the Essendon DFO accident and etc are always so very late - lack of resource (and good old Covid) seem to presented as acceptable reasons for the extensive delays. Now they can't even bother investigating the fatal Jodel accident - where the safety case demonstrates some bloody big holes in the magical CASA safety net. But, the really hard part to swallow is that when a final report is actually presented, it is about as much use as a chocolate firewall. Yet our short wheel base Popinjay, intent on striking the big note (look at me) feels free to utilise scant resources, time and public money to go go public - claiming:-

"I guess me coming in with a due diligence and a new set of eyes, we are to taking a review of the data that we hold there and that’s being done in conjunction with Geoscience Australia,” he told News Corp Australia/Sky News.

BOLLOCKS.............!

And via the MH370 thread: https://auntypru.com/forum/showthread.php?tid=24&pid=12654#pid12654

Quote:Of Temerity - writ large.

Tonight (in Australia) Sky News will present a documentary relating to the MH 370 event. I wonder what a world wide audience will make of the Australian Transport Safety Bureau (ATSB) sorry track record in this story? How will the performance of Dolan followed by Hood be assessed? We have a fair idea, based on comments and correspondence received; but, those are now part of the legend surrounding the 'mystery' of not only the 'disappearance' but of the way in which the event was stage managed.

History aside, the ATSB have a new public face - Mitchell - you can meet him from about the 28:00 minute mark in the video below.


I confess that after about five minutes of that Senate GA Inquiry session, I'd picked a video clip to add to his own file:-


Whether or not Sky invited the early release of the ATSB piece 'starring Angus' or not is immaterial. The 'work' done on the investigation is not ATSB work; they ( including Angus) had no input to the research. Perhaps Sky just wanted to add ATSB credibility to the piece - who'd know, or care? What the majority of aviation folk do care about, very much, is the pathetic performance of the ATSB accident investigation reporting.

There exists a a very real list of current tragic events; all of significant value to overall safety performance, which have not been finalised (years). There exists an even longer list of almost risible reports into accidents, which, after an unreasonably long time between 'accident' and publication provide little of intrinsic or practical value to the aviation community.

The never ending mantra of 'scant resource' (and the handy 'Covid' thing) have long been used as a standard excuse for piss poor performance. Yet wee Angus can find the time to step into the spotlight's glare and revel in the close up shots - and talk about 'his' take on the MH 370 debacle. Perhaps that time could be better spent getting reports finalised; getting reports to have substance, benefit and increased safety awareness. Hell, he could even begin to clean up the seriously tarnished track record, that of being the best 'top cover' agency in town - credible deniability - abandoned in favour of real accident reporting (I wish). I really want to know why ATSB washed their hands of the Jodel fatal (can't be bothered?) yet have time to fanny about on TV promotions, particularly when one considers the hourly rate of pay our Angus tucks away.

Anyway; no doubt the world and its wife will be able to see the new face of the ATSB in all it's hoary glory this evening.

Toot - toot....

Ref: https://flashnews.com.au/show-mh370-the-final-search!12116



"..Absolutely, we'd stand ready to assist if we were asked..."

As a point of difference to the Popinjay's bollocks 'due diligence' and 'new eyes' on MH370, I draw attention to perhaps the one and only credible (former) ATSB 'subject matter expert' on MH370 Peter Foley: (from 07:25)


 

And now via Linkedin:

Quote:

Angus Mitchell

Chief Commissioner/Chief Executive Officer


I am looking forward to attending the AusRail Plus Conference and Exhibition in Sydney next week to represent the ATSB, where I will participate in an industry panel facilitated by AusRail CEO Caroline Wilkie to discuss – What can rail learn from the aviation industry?

For those who are interested, further information can be found at https://www.ausrail.com/

Hmm...no comment - 


 MTF...P2 

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RE: The search for investigative probity. - thorn bird - 02-28-2022

errr scuse me?

Maybe for gods sake, don't flog off all your railway stations to development sharks.

For gods sake don't bring in a railway act that has "safety" as its one and only prime objective.

For gods sake don't create an independent government agency unaccountable to anyone to produce and enforce the prime objective with no oversight or accountability.

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RE: The search for investigative probity. - Cap'n Wannabe - 02-28-2022

Came across this on Farcebook...

Quote:Thank you to the admins for admitting our company to PLA.
We specifically wanted to address the ATSB report into the C172K accident outside of Canberra. We know that some of you feel strongly about this, and we recognise the sorrow and pain that the families of the victims (and we know some family members) are feeling, and will no doubt feel for some time to come.
The discussion we want to have, is about some of the comments we have seen on social media in general. There seems to be a consistent talk about stalling, and the need to avoid getting near the stall speed and slow speed flying.
These discussions do not help. Nor does, unfortunately the ATSB report.
These Loss Of Control-Inflight (LOC-I) accidents occur, and continue to occur because of a general misunderstanding that is pervasive throughout the industry: that is that stall occurs because the pilot flew too slow. WRONG. This thought process has, does, and will continue to kill pilots if it is allowed to continue. An aircraft does not stall because it flies too slowly. It stalls only because it exceeded the critical Angle of Attack. Most pilots as some level do know this, but it’s the lack of understanding about how AoA and speed relate to each other; how to use airspeed EFFECTIVELY as stall protection.
We want to be very clear here. In this situation, and in all the accidents that we have studied (and there are HUNDREDS) and the accidents we use as case studies in our courses, we do not blame the pilot. It is NOT their fault.
The problem in the industry is that pilots are trained to stall as a manoeuvre. Symptoms of a stall are confused with the symptoms of slow speed flight. They’re not trained to recognise the symptoms of a stall and they fail to recover when they’re not flying at a slow speed. They’re not trained to recover from a stall when they’re not expecting it.
Every pilot who has crashed and suffered a LOC-I has done stall training. The problem is when a stall occurs and the pilot is NOT expecting it. Going out and doing a “stalling lesson” will not prevent this. The psychological and physiological “shock” that occurs when an aircraft departs controlled flight is unrecoverable if you have not been trained.
We want to be clear at this point about something else too. We are not posted this and creating this conversation as a “drumming up business”. We wish our business didn’t have to exist; but it does. The real numbers of LOC-I in GA would absolutely shock most pilots. We are posting this so you, as pilots who undertake specialised, “higher risk” flying ensure that you have a very clear understanding of what can happen when it goes wrong, and that most pilots (and we say most, because our research shows it) do not recognise when things are about to, and when they do, go wrong- until it’s too late.
We, as an industry are responsible for setting and accepting the standards. PLEASE, don’t let this keep happening- stay safe, know your aircraft, know your limits, know yourself.
https://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-016/

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RE: The search for investigative probity. - Kharon - 03-01-2022

Of opportunity lost.

Or; the great waste. Only my opinion - but, perhaps more than any of the recently published ATSB accident reports this particular item - HERE - highlights the loss of an invaluable resource; the 'Crash Comic'.

"These Loss Of Control -Inflight (LOC-I) accidents occur, and continue to occur because of a general misunderstanding that is pervasive throughout the industry: that is that stall occurs because the pilot flew too slow. WRONG. This thought process has, does, and will continue to kill pilots if it is allowed to continue. An aircraft does not stall because it flies too slowly. It stalls only because it exceeded the critical Angle of Attack. Most pilots as some level do know this, but it’s the lack of understanding about how AoA and speed relate to each other; how to use airspeed EFFECTIVELY as stall protection."

Loss Of Control (LOC1) should be, along with flight into IMC topics, examined in detail, put into a narrative form and published regularly. Your old mate Google will, if asked properly provide dozens of weighty tomes; all academically correct; it will provide all manner of 'risk assessment matrix and proforma which can 'quantify' a risk level. All mind bending boring, if essential. The 'Crash Comic' on the other hand provided many examples - the time honoured "I learnt about Flying" series which distilled a pilot's adventure into 'brass tacks' common sense understanding of where, when and how it all turned to worms. Invaluable short narratives which 'stuck' and, I believe prevented many a potential accident. The report (above) from the ATSB fails, dismally, to provide anything in the way of prevention, reoccurrence or increased awareness; so why bother spending time and money providing it, if it serves no purpose? Apart from the obvious..

Our Ag pilots and fire bombers and the folk who train 'em could provide a page or two of valuable insight; probably be happy to do so in the interests of general education. There is a vast storehouse of knowledge available to those who seek it; from dry scientific theory to yarns told over a beer. The thing missing - nowhere to publish them. Perhaps its time ATSB got serious about getting knowledge and a safety message out into industry in a format that delivers the message.

Back in the day, every flight office and flying school had a library of the 'Crash Comic' all dog eared from constant use; the articles discussed when the weather was liquid and lousy; read by itinerant juniors (and seniors) on charter wait time. The articles served a useful purpose; I can't imagine the Kickatinalong flying school leaving a copy of the latest ATSB report on the coffee table - can you?

Toot - toot.

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RE: The search for investigative probity. - Kharon - 03-09-2022

Side bars and dustbins.

Usually, when P2 is rummaging in the bins, we haul him out by the scruff, hose him off and sift through the 'finds'; alas, he ain't done yet. But, we can see where the search is heading - HERE - with more to follow.

From amongst the rubble the shade of Bruce Rhodes appears, dragging along the Middle Island accident; reeking of flawed system and little in the way of sound advice to prevent recurrence (or reoccurrence even).

There are a couple (or three) elements in the ATSB report which subtly influence the opinion of the reader; for example the coy use of the term 'semi-aerobatic' manoeuvres. That there is no such thing exemplifies the desire to shift both focus and blame away from the radical flaws. It implies a willingness on Rhodes part to flout the statutory rules, the tenets of good operational sense and the experience of other operators performing similar work.

Semi aerobatic - is a nonsense. A manoeuvre either is a recognised, named, legitimate, deliberate, calculated aerobatic act; or it it not. If not then the manoeuvre falls within the ambit of 'normal' operations and quite legitimate. Find me a pilot who has not 'tossed' the airframe about 'a bit' just for fun; steep turns, a wing over, a little negative 'g' after positive 'g'. Harmless diversion - unless essential. There is no technical comparison between the 'g' forces experienced during aerobatics and the  'routine' in flight 'bit of fun' Rhodes and Co. performed. The forces experienced by the passengers were nowhere near those you would get on say a ride on a Big Dipper - in the region of 3.5 positive - 0.5 negative. So why the slur and false implication that somehow a 'bit of fun' equates to a poor safety culture and used as the foundation for the implication of a 'cowboy' operation? 



Secundus: The same deceptive 'methodology' has been applied to the 'Operations Manual'. IF any part was thought to be substandard - at the acceptance stage; then surely the CASA inspector would have pointed the deficiency out, in writing, and delayed the issue of certification until those concerns were addressed. So what happened? P7 and I sat down and took a look at the Rhodes operation - it took about 45 minutes to produce a page and a half 'procedure' which would have eliminated 90% of the clearly defined 'danger' areas; simple enough stuff which would have covered the operators arse in the rare event of and engine failure at a critical point - despite the astronomically high odds against it - the bet was covered. So why was the deficiency not brought to the operators attention; and, why was a certificate issued against a potential risk? Where was the much mentioned superior CASA safety oversight?

There, got that off my chest; back into my box I go.

Toot - toot...

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RE: The search for investigative probity. - Kharon - 03-11-2022

"There we were:"

Down to 2000 ft, cloud covered high ground ahead, heavy rain on the left, storms behind, the terrain to the right tiger country: time to put the aircraft down and wait. Or, if you prefer - a glider retrieval from a paddock somewhere. Whatever; there is a need to land on something other than a prepared surface. Much to consider, many variables, many risks and not a lot of time for navel contemplation.

There are several ways of approaching the 'problem' - for me, it's still a subliminal 'habit' as taught from day one, looking for viable spots to put down into - should the whatsit hit the windmill - unexpected like. But, I digress; the topic is the difference between precautionary search, strip inspection and a forced landing. As may be seen in the Middle Beach event; a routine strip inspection very quickly became a forced landing.

We still, despite the science and technology available, to this very day don't know why a simple, robust piston engine failed. It can only be one of four possibilities; to wit a seizure or component failure; air, spark or fuel. ATSB still have NDI and gave up. Strike one.

The engine failed in what is probably (mathematically) the worst possible place - there was nowhere 'safe' to go. It begs the question - why was the aircraft ever allowed to progress so far into a 'dead end' - 'in the unlikely event of' etc. Should the OM have had a detailed procedure - and a travel limit - specified for the 'dead zone'? IMO yes it should. Should the aircraft have always been in a position to effect a forced landing? Again, yes. So, where is the radical; who's to bless and who's to blame? Equal shares I'd reckon. Yes, there should have been a location briefing - you know the type of thing - "landing to the North blah, blah' etc. Yes, the CASA inspector should have picked up the 'familiarity' and 'loose' procedure, perhaps suggesting a rethink of the existing 'normalised deviance' and even gone so far as to suggest alternative methods. CASA did accept the operation 'as writ' without demure... 

But Gods forbid CASA ever recommended to following load of Bollocks; and yet, they do. The blind leading the unspeakable along dangerous pathways - without any thought bar fooling the world into believing its 'safe'.


"CASA advised that many flying training organisations have adopted the guidance provided by the Aviation Theory Centre, a publisher of commonly-used flight training manuals in Australia. This guidance included the following for carrying out a safe approach and landing at an unfamiliar field with engine power available:"

A classic example of Ass-U Me - never assume that full power will be available - always expect the worst - and mutter the right words to the gods of chance (and fate for - good measure)..

• conduct a first inspection at 500 ft AGL circuit height, slightly to the right of the landing area (to check for obstacles on approach and departure and general condition of the landing surface).

Deceptive wording; easy to confuse. From the left side of the cockpit - strip on the right? Bullshit - in a 'standard' light aircraft - the LEFT wing-tip placed of the selected paddock area will provide adequate spacing for a 'normal' short field landing - also if the turns are made to the left (as usual) the need to learn a seldom practised right hand approach and associated errors is eliminated. From 500 feet, on a dull day not too much of the essential detail can be observed; you have now wasted vital time when conditions are 'pressing' - on the 'wrong side' of the paddock.

• conduct a second inspection at 200 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (for a closer examination of the landing surface and other hazards)

So, now we allow what, 30 seconds - to descend another 30 to realign and then, return to 500 feet two minutes later? WTD - Raining pick handles - 200 feet nerves tingling, power on and  -'bang' - engine fails. What now I wonder, royally ducked is the right answer.


• a third inspection at 50 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (if required for a closer inspection of the landing surface)

So, we make it back to 500' (another minute gone) get sorted out (another minute) then make a descent of 450 feet (tick tock) do a low pass at 50 feet (tick tock) then apply power and climb back to 500'. 50 feet - power on - bang - engine fails - what now? See the above and multiply by five. You are now dead - forced landing, in climb configuration, 20 knots above full flap slowest landing speed. So this all becomes ever so slightly esoteric, risible and pointless.


• conduct the inspections with some flap extended (to provide a slower speed and other advantages, such as a smaller turn radius and better view from the cockpit due to a higher nose attitude).

Spot on (not) - you can see to the side Ok. but that ain't where you're going, is it? The whole point of any 'inspection' is to get a look at the bloody surface ahead - the bit you want to land on; this to avoid the short stump or part covered log; or the left behind iron fencing stakes which can really spoil your day.

But what in seven Hell's does any of this 'theoretical' hogwash have to do with routine beach landings? Not much - IMO. 

“I cannot here withhold the statement that optimism, where it is not merely the thoughtless talk of those who harbor nothing but words under their shallow foreheads, seems to me to be not merely an absurd, but also a really wicked, way of thinking, a bitter mockery of the most unspeakable sufferings of mankind.”

Or, blind 'em with science then baffle 'em with Bullshit.

Selah.

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RE: The search for investigative probity. - Kharon - 03-15-2022

Signposts - to Perdition?

Towards the middle of the P2 post - HERE - you will find a short paragraph - which is the beginning of a bread crumb trail. It is an interesting trail to those genuinely interested 'real' safety matters, rather than the legal/political aspects of accident investigation and reporting. The links provided take you on an 'interesting' journey through the twisted pathways leading to the 'nothing to see - move along' Jedi mind trick.  But there is much to see, non of it worth the cost..

P2 - "This brings me to the safety issues section of the FR and in particular under the heading of 'Regulatory surveillance – scoping of surveillance events"....

Snipe and counter snipe artfully disguised to cover over the indolence, arrogance and ineptitude of two very expensive 'safety' authorities. Masters of disingenuous obfuscation and good old fashioned arse covering. 

ATSB. - "The ATSB collected a significant amount of evidence and conducted an in depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator".

Discontinued; time, money and effort wasted with no positive reporting aimed toward preventing similar 'attitudes' toward 'how' a company should operate etc. No useful stuff like redefining 'command' prerogative and authority. Not even a mention of the  piss poor descent planning and monitoring leading to a panic induced lack of cockpit discipline. One could (ATSB should) strip the ATR event back to company culture, aircrew selection and training: and, management 'requirements' on the crew. There is food for thought there, but now, beyond the ambit of ATSB discussion or interest.  'Nuff said..

For us, it's time to pay a visit to the flight deck. We can start a few minutes before Top of Descent;

ATSB - "As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems". (abuse of language).

Clearance and ATIS noted, briefing complete; power back and, down we go - standard rate; a tick short of 'red line' speed, which is unwise, as we discover.

"While passing through about 8,500 ft, the aircraft encountered a significant windshear that resulted in a rapidly decreasing tailwind". Bollocks; try the inversion on for size. WTD has a 'rapidly decreasing tail wind got to do with it; rubbish! Ground speed :: Airspeed? Ring any bells?

"This led to a rapid (15 small knots?) increase in airspeed, with the airspeed trend vector (displaying predicted speed on the primary flight display) likely indicating well above the maximum operating speed (VMO) of the aircraft of 250 kt.

No kidding Sherlock - wind aloft + 20 - ATIS 5 knots - rate of descent monitored to compensate for anticipated conditions. No?  Then we have a command problem, a training problem, an education problem and an attitude problem, not to mention over reliance and a dependency on a dumb machine. But, no matter. 

ATSB - "The captain took hold of the controls and made nose-up pitch control inputs without immediately following the specified take-over procedure and alerting the first officer of his intent." - See above.

And so, a safeguard becomes a liability; at high speed subject to rough handling - and, predictably, it broke. Busted; but tough enough to get the aircraft back to Earth in one piece. Severely 'Grounded' one would hope - tea and biscuits with the CP to follow. Enforced by CASA and ATSB. Nope; a quick wipe over with an oily rag, and off the crippled airframe trots to complete a further 15 sectors. It is remarkable that not one pilot realised that the airframe flew cock-eyed - the AP just compensated while they played at being pilots. 15 sectors and not one pre-flight inspection noted that the tail plane was twisted? Unbelievable - and investigation discontinued - (expletive deleted)...

Yet, 'tis true. Both ATSB and CASA have decided to 'discontinue' the investigation on the flimsiest of excuses. There are deep, across the board systemic and operational aspects to this incident. That no one was killed is just dumb luck; the fundamental problems much deeper than the glib, slip-shod response from the very expensive 'safety' agencies.

Disgraceful; yet this band of Mutts parade, prance and preen as 'the' doyens of public safety in all matters aeronautical - Bollocks...

Toot - toot.

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RE: The search for investigative probity. - Kharon - 03-26-2022

For what its worth; ATSB have finally managed to publish a 'report' (for wont of better) on the Airbus v Jabiru in the crowded, confused skies around Ballina NSW. ATSB has taken two years and four months to produce the 'report'. Read it if you must and take note of the insightful, clearly defined safety solutions - when you find 'em let me know; for I cannot.

Toot - toot....

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RE: The search for investigative probity. - Peetwo - 03-26-2022

For what it's worth:  AO-2021-028 - 

Courtesy the Ghost Who Walks, via the Popinjay media minion:

Quote:Landing gear not retracted after take-off demonstrates how diverted attention or focus may result in errors of omission

Quote:Key points:


Q400’s landing gear not retracted until aircraft reached 15,900 ft;

Aircraft was below the maximum landing gear operating speed but exceeded the maximum altitude at which the landing gear could remain extended, although there was no effect on aircraft serviceability;

Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed.

A flight crew’s omission of key calls on take-off and incorrectly completing the after-take-off checklist contributed to a Q400 turboprop airliner’s landing gear not being retracted after take-off, a new Australian Transport Safety Bureau investigation report details.

The QantasLink Bombardier DHC-8-402 (Q400) aircraft had departed Sydney Airport on 12 July 2021 to operate a scheduled passenger service to Albury with two flight crew, two cabin crew and 22 passengers on board.

Due to the relatively light weight of the aircraft and the use of normal take-off power, the flight crew expected an increase in aircraft performance, the investigation notes. The captain recalled being very focused on the correct pitch attitude for take-off and monitoring the airspeed in relation to the flap speed limit.

Later during the climb, the first officer provided the after-take-off public address announcement to the passengers. This call, which is made after passing 10,000 ft or when the aircraft is established in the cruise, also serves to notify the cabin crew that the flight deck is no longer ‘sterile’ (that is, cabin crew are free to contact the flight crew outside of emergency situations).
At that point a cabin crew member contacted the pilots, asking if it was normal for the landing gear to still be extended. The flight crew immediately looked at the landing gear panel and identified that the handle was down with 3 green lights illuminated, indicating that the landing gear was still extended.

After confirming that the aircraft‘s speed was below the maximum landing gear operating speed (of 200 kt), the flight crew retracted the landing gear. However, as the aircraft was at an altitude of about 15,900 ft, this meant the aircraft had exceeded the maximum altitude at which the landing gear could remain extended, of 15,000 ft, although this had no effect on the serviceability of the aircraft.

“The ATSB found that both pilots were heavily focused on aircraft performance after take-off, so the positive rate and subsequent gear-up calls were not made, and neither pilot identified these omissions,” said ATSB Director Transport Safety Dr Michael Walker.

Subsequently, when completing the after-take-off checklist, the pilot monitoring provided the ‘landing gear’ challenge and the pilot flying incorrectly called ‘up, no lights’ in response. Both pilots observed that the 3 green landing gear lights were illuminated but neither recognised that this was problematic for this stage of flight.

“It is likely that both pilots had a strong expectancy that the landing gear had been retracted after take-off, and they probably conducted the after-take-off checklist with a high degree of automaticity, rather than consciously looking for what was required.”

The investigation report notes that the flight crew interpreted increased levels of vibration while airborne as being related to a propeller balance maintenance log entry. In an effort to reduce the noise and vibration, the crew reduced the climb speed. This reduced the abnormal indications and seemingly confirmed that the propeller balance was the source of the problem, and is consistent with the effects of confirmation bias.

Dr Walker said the occurrence demonstrates how diverted attention or focus may result in errors of omission, especially where a task may be reliant on standard verbal cues.

“Highly-repetitive, routine tasks may result in pilots developing strong expectations that a task has been completed, even if it has not been, and make it difficult for pilots to identify an omitted action,” he said.

“Accordingly, it is essential that when flight crews are completing checklists, they focus on confirming that the relevant conditions have been met.”

Dr Walker said the investigation did consider what, if any, impact reduced flying levels and skill degradation due to the COVID-19 pandemic may have had on this occurrence.

“While both pilots met minimum currency requirements, and both had recently undertaken a proficiency check, the first officer had conducted less than one third of their normal amount of flying in the previous 90 days and had not conducted any flights for 11 days prior to the occurrence flight,” he noted.

“Overall, there was insufficient evidence to conclude that the first officer’s reduced flight recency contributed to the procedural errors made by the flight crew. The investigation also noted that the operator was aware of the potential issues associated with reduced flight recency and had introduced measures to mitigate the risk.”

The report also notes the cabin crew displayed a high level of vigilance regarding the aircraft state.

“Their willingness to bring the extended landing gear to the attention of the flight crew allowed the the problem to be identified and for the landing gear to be retracted as soon as possible,” Dr Walker said.

“This highlights the strength of timely communications between crew members.”

  
In response, from one of our resident IOS AAI SME - 

Quote:Firstly, why on earth is this the subject of an ATSB Investigation, aside from giving the Dr  something to do and prove how smart he is! ART FOR ARTS SAKE! And what does this exercise cost? Why not focus on real issues like buildings on airports, CASA regulatory impact on safety, hi cap maintenance systems etc. Instead, they discontinue  investigations and print ones the industry already has sorted!
The ATSB costs approx 30 million PA and I can't recall actually learning anything for years, nothing!

LOSA & TEM concepts accept we all make mistakes and have been in use all over the world for years. The company would have reviewed this and briefed their Training Capts. The crew will never do it again. Worst case scenario is the aircraft won't accelerate as expected. That's normally pretty obvious. Plus the crew did the right thing with speed/gear selection. The gear won't fall off!!! Sure, it's an unusual event, but this sort of thing is best covered by a "fire side chat" with the fleet manager or HOTOC.

I did it momentarily once on take-off out of Scone, in a Navajo, when I was a kid. Radio call right on takeoff from inbound traffic - distraction, that's it! Lesson - don't get distracted! I should report my 1983 incident to the ATSB. They'd love to do a "systemic" investigation into me?

I could go on.....!

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 06-26-2022

Spot the trend??

Reference Accidents Domestic thread:

(06-16-2022, 09:56 AM)Peetwo Wrote:  Drone taxi crash report - "Where's the kill switch?"  

Via Popinjay central: 

Quote:
RPA taxiing loss of control incident highlights the importance of fatigue management and controller design



An Australian Transport Safety Bureau investigation into a 19 June 2020 loss of control incident involving a remotely piloted aircraft (RPA) while it was taxiing following a maintenance flight highlights to RPA operators the importance of fatigue management and controller design.

After landing at Bruhl Airfield, Queensland after completing a successful autonomous test flight, the pilot of the RF Designs Mephisto RPA - a high-performance autonomous testbed which has a 2.6 m wing span and a 35 kg max take-off weight - toggled the controller’s automatic mode switch to disengage the aircraft’s automatic mode for taxi back to the hangar, the investigation report details.

The pilot then increased the throttle to provide the RPA with sufficient momentum to taxi. As the RPA turned towards the pilot, the pilot determined that it was not responding to commands to reduce the engine thrust. The pilot considered attempting to arrest the RPA by hand but determined it was moving too quickly and instead toggled the automatic mode switch to regain control and turn it away from bystanders.

The pilot then directed the RPA across the airfield and it came to rest against the perimeter fence, resulting in minor damage to the aircraft’s skin.

“The ATSB’s investigation into the incident determined that the pilot did not correctly disengage the RPA’s automatic mode,” said ATSB Director Transport Safety Stuart Macleod.

“Subsequently, when they increased the throttle to provide the aircraft with momentum to taxi back to the hangar the ‘abort landing’ function activated, increasing the throttle to maximum and overriding the pilot’s commands to decrease throttle.”

Mr Macleod noted this incident has 3 key learnings for RPA operators.

“RPA operators should be mindful of the risk of fatigue, particularly in high tempo commercial operations,” he said.
“Even when fatigue management is not mandated, operators should ensure that their fatigue management processes are robust and effective.”

The incident also highlights the importance of controllers being as simple and reliable as possible.

“If a control leaves room for human error, then it will increase the risk of this error occurring even if procedural controls are in place. Consideration should also be given to a system that allows the remote pilot to shut down the aircraft immediately in the event of an unexpected state or failure.

“Lastly, operators should be prepared for the RPA to do something unexpected and know and frequently practice emergency procedures.”

Read the report AO-2020-035 Loss of control during taxi, involving RF Designs Mephisto, remotely piloted aircraft Bruhl Airfield, 2 km south-west of Tara, Queensland on 19 June 2020

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Plus:

OK: and - then what????

Popinjay - ""Consideration should also be given to a system that allows the remote pilot to shut down the aircraft immediately in the event of an unexpected state or failure."

What a bloody good idea - a 'Kill-switch" - pearls of wisdom drop from the ATSB boss; although from which end of the boss they dibble we ain't sure.

1.852 converts Knots to KpS. 1 nm/sec = 1.852 KpS. 30 knots = 0.5 nm/ minute: so do the maths -  35 Kg @ 30 Knots = 0.926 Kilometres distance travelled - after the 'kill switch is toggled. F= MA provides the impact force of a 35 Kg thing with a 2.6 meter wingspan hitting something. All very esoteric - but if you ever want to experience F=MA in the real world, try this. Place your thumb on the workbench and allow a 0.5 Kg hammer to drop from eye height onto it. Quite a wallop ain't it; sore for a week at least, for a month's worth of pain - swing that hammer with some force (malice aforethought) - you'll get the message fast enough.  Sure, it is not a regular occurrence, but it happens and there are no 'fail safe' measures to prevent it (bar common sense). My hammer weighs in at 24 ounces (0.68 Kg) the fail safe is me. The 'drone' under consideration has no built in 'fail safe' - loose control of it, at speed and altitude and the operator who hits the 'kill' switch has no further control (non whatsoever) from that moment over 35 Kg @ 10 knots = 18.5 kilometres per hour/ 60 = 0.3 K per minute. Allow what; say a 1.5 minute descent after the 'kill' that's 2/3 kilometre (ish) travelled before it reaches the deck - out of positive control. Kill switch - yeah, OK but what about 'control' after the event - the 'impact' maths get complicated from here - but it is quite a whack. Every aircraft has an alternate means of control after say an engine failure- Aye; 'tis limited but it at least it has a fighting chance of not hitting Bunning's out of all control on a Sunday morning.. Bring on the Drones if you must - but lets have some 'fail safe' control built in with a little more imagination than just a stellar example of ATSB safety thinking like - "hit the kill switch" (and then what?)..........A well trimmed man-hole cover on descent....

And now this, from Popinjay central..

Quote:RPA fly-away results in minor injuries after shattering hotel room window



Key points:

• DJI Inspire 2 became unresponsive to control inputs before colliding with hotel window, injuring an occupant;
  
• As a result of accident, DJI has updated user manuals for a number of products to provide additional guidance;
  
• Drone fly-away events are not rare, and there may only be a few seconds to properly respond when such an event is about to occur.
  

A fly-away incident where a DJI Inspire 2 remotely piloted aircraft (RPA) collided with a hotel window, injuring an occupant, serves to remind operators to be familiar and well drilled in emergency procedures, an ATSB investigation notes.

On 15 January 2021, the DJI Inspire 2 was being used for aerial photography and videography above Cockle Bay in Darling Harbour, Sydney.

Shortly after take-off, the RPA unexpectedly accelerated away from the pilot, and became unresponsive to control inputs. It accelerated to its maximum speed and, a short time later, collided with the window of a hotel adjacent to Darling Harbour.

The RPA shattered the window but did not penetrate it. A person inside the hotel received minor injuries from flying glass, and the RPA was destroyed.

The ATSB investigation into the incident found the compass of the RPA failed due to electromagnetic interference during flight, leading to the fly-away.

“Occurrence data reported to the ATSB indicates RPA fly-away occurrences are not rare,” ATSB Director Transport Safety Stuart Macleod said.

In the four years from 2017 to 2020, 94 occurrences of partial or complete loss of transmission and/or reception of digital information from an RPA were reported to the ATSB.

The majority of these occurrences resulted in damage to either the aircraft, property, or both.

“It’s important RPA pilots ensure they are familiar and well drilled in emergency procedures, as well as being proficient in flying in all flight modes,” Mr Macleod said.

Mr Macleod noted that during an RPA fly-away, there may only be a few seconds in which a pilot can take avoiding action.
“In the event of a compass failure, switching to the fully manual attitude flight mode may assist regaining control of the RPA,” he noted.

Following a review of the occurrence, the RPA’s manufacturer, DJI, updated the user manuals for a number of its products, including the Inspire 2.

The changes provide additional guidance to users regarding the use of the fully manual attitude flight mode in the event of compass interference.

Although not contributory to this occurrence, the ATSB investigation also found the pilot did not follow the operator’s emergency procedures, or comply with the regulator’s operational permissions to fly in restricted airspace.

“Adhering to operational guidelines and limitations remains important for ensuring the safe operation of RPAs,” Mr Macleod said.

“This is particularly true in populated areas, where risks are potentially elevated.”

Adhering to the limitations and guidance provided by the regulator will ensure these risks remain as low as reasonably practicable, Mr Macleod concluded.

Read the report: AO-2021-001 Loss of control and collision with terrain involving DJI Inspire 2 remotely piloted aircraft Darling Harbour Sydney, New South Wales on 15 January 2021

MTF...P2 

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