The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Kharon - 02-01-2023

Of Cats and Canaries.


Or, of Greg and his 'Gong'; or, the sinister side of system. There's more suggestive titles; all part of the considered collective debated opinion. But not on 'why' Hood got his gong; that part may be clearly defined through public documents. It is the 'how' that creates the disgust.

The 'how' raises other discussion and questions. Questions to which there will be no answers forthcoming, not ever. 'Tis done and that's the end of it. The reasons for this doing are simple enough and many believe those reasons have devalued the AO system; and, potentially cast a dark shadow over all those who have won the same award.

“For distinguished service to the national transportation and aviation industries”

That quote, stand alone is, deceptive to say the least, (disingenuous with a dash of cynical smugness is probably nearer the mark - IMO). The dark side neatly tucked in behind the words. Words possibly even written by those at who's behest Hood was operating, as requested. Is it well within scope of reasonable probability that it was scripted by the same people who promoted Hood for the award/ reward? Was this award gifted for services rendered to the benefit of 'system' and those within, rather than to the industries served by the Quango system of 'public 'service'? Reasonable questions?

Follow Hood's pug marks through history if you will – from the McCormack tenure at CASA, for it is there that the tale begins, all freely and fully available on Senate video recordings, transcripts and FOI. Did clever folk in the backrooms identify Hood as the 'useful idiot' – a willing accomplice , eager to help roll the dice in favour of the official narrative? Before the Pel-Air drama, the dark arts had been practised and refined in a couple of other 'debatable cases'. These carefully, cleverly managed 'success' cases failed to generate much in the way of industry or political 'noise' : not until Pel-Air reached a crisis point and the Senate RRAT committee became embroiled. Elevated (and possibly exposed past further use) Hood was then quietly dispatched to Air Services to produce 'courage' wrist bands and cartoon posters; but, somehow, the highly qualified, competent lady in charge of ASA became undermined and departed the fix; while Hood's old mate Halfwit rose to the top of the pile. Job done ? Then off to the ATSB he trots. We now must consider the MH370 debacle and Hood's role in that disgrace; exit Beaker enter Hood, uttering dire threats of imprisonment for speaking out of school; and the subsequent departure of a few good men from the investigation begs questions. 

You couldn't make this stuff up; any careful examination of history reveals the pattern and result of the track from insignificant 'administrative' type to 'the gong'. For 'services rendered.' If you dismiss Hood from the story as a 'Cats-paw' or useful idiot, or even a willing accomplice it leaves just one question standing unanswered. Who are the cynical, clever people behind the scenes who identified Hood as 'useful' and set him on his path to 'glory'? Oh, there's no conspiracy theory to contemplate here, not at all. A protection racket perhaps; one designed to maintain control of and funding for a lucrative easy work life with all care but no responsibility taken for the shambles the administration of Australian aviation has descended into. Nice work – if you can get it.

Aye; Give Hood his 'gong' – a good riddance I'd say. Use by date expired; I wonder who the next contender for the 'role' will be? No doubt we shall, with patience, time and the record see.


“We are oft to blame in this, -
'tis too much proved, - that with devotion's visage,
and pios action we do sugar o'er
the devil himself.”


Toot – toot.

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RE: The search for investigative probity. - Peetwo - 02-03-2023

Of Cats and Canaries: Part II

In follow up to the excellent (nailed it) "K" post above, I'd like to refer in full to a post of mine from pretty much exactly 5 years ago...

Via the dots-n-dashes thread: 

(01-23-2018, 06:44 PM)Peetwo Wrote:  The Iron Ring & the Hooded canary -   

Quote from this week's SBG: Speak softly; yonder, as I think, he walks.

 "...The opening gambit is readily seen in the media – see: there’s Hood, doing a Geoffrey Thomas (he of Sunrise fame). This is not a top quality act, but ‘twill suffice. Firstly, we must examine the ‘props’ used, the title for a start will impress – ‘top dog in the Australian Transport Safety Bureau (ATSB) and a natural performer. Always seen looking ‘windswept’ and interesting, dressed in his canary yellow vest, wearing his ‘courage’ wrist band. The ‘shrinks’ would have a field day with that little lot, no matter. The long suffering public will not know the lack of qualification, or the association with some of the most disgusting ‘Acts of bastardy’ which hover about the ‘windswept’ visage. They will have no concept of conflicted interest or even ‘departmental’  manipulations. No; they just see the ‘fluff’ and hear the soothing words, reassured; they happily hop on the cheapest flight and toddle off to booze in Bali..."

 &.. from SBG post #95:

"...The main reason being that while HVH was the CASA Executive Officer ultimately overseeing the enforcement actions against both PelAir and Dominic James I also have, on good authority, information that HVH was the designated co-ordinator/liaison officer dealing with the FAA audit team and therefore the consequential cover-up of the actual FAA findings that could have led to the possible Cat II IASA rating..." 

So with interest piqued the BRB have tasked me to re-examine the HVH crumb trail with the intent to join some further chronological dots & dashes on the PelAir cover-up timeline (i.e Pel-Air: A coverup: a litany of lies?)...

To begin let's revisit the HVH CV up till the time he started with CASA:

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Air Traffic Controller

Company Name
Royal Australian Air Force  

Dates Employed
1980 – 1990  

Employment Duration
•10 yrs  

Location
East Sale, Sinai Desert, Darwin, Townsville

---

Air Traffic Controller

Company Name
Airservices Australia  

Dates Employed
Jan 1990 – Apr 1993  

Employment Duration
•3 yrs 4 mos  

Location
Melbourne Adelaide Alice Springs

---

Instructor - Centre for Air Traffic Services - University of Tasmania (Launceston)


Company Name
Airservices Australia  

Dates Employed
Apr 1993 – Dec 1994  

Employment Duration
•1 yr 9 mos  

Location
Launceston

---

Team Leader, Group Leader, FIR Manager

Company Name
Airservices Australia  

Dates Employed
Jan 1995 – Mar 2002  

Employment Duration
•7 yrs 3 mos  

Location
Brisbane ATC Centre

---

Manager Melbourne Centre


Company Name
Airservices Australia  

Dates Employed
Apr 2002 – Dec 2005  

Employment Duration
•3 yrs 9 mos  

---

Manager National Towers and Regional Services


Company Name
Airservices Australia  

Dates Employed
2006 – 2008  

Employment Duration
•2 yrs  

Location
Canberra, Australia

---

As can be seen HVH had all the right pedigree and Quals to continue a long career with progression up the gravy train at ASA. However inexplicably HVH leaves ASA to take up a lesser/nothing position at CASA :

---

Group General Manager Personnel Licensing Education and Training

Company Name
Civil Aviation Safety Authority  

Dates Employed
2008 – 2009  

Employment Duration
•1 yr  

Location
Canberra, Australia

---

However with the arrival of McComic in 2009, it would seem HVH's obvious talents (??) were noted by the new DAS and once again Hoody's star was on the rise.

Extract from CASA Corporate Governance webpage 2013: https://www.casa.gov.au/standard-page/corporate-governance-4
 

Quote:Operations Regulations Implementation

Greg Hood
Executive Manager (Program Director)
Phone: 02 6217 1118
Email: greg.hood@casa.gov.au

Profile
Mr Greg Hood is a glider and fixed-wing private pilot. He commenced his career as an air traffic controller in the Royal Australian Air Force. His nine years in the military included postings across Australia, and he served with the Australian contingent to the Multinational Force and Observers in the Sinai Desert.

From 1990, Mr Hood spent 17 years with Airservices Australia, in roles including Manager of the Melbourne Air Traffic Control Centre, Manager National Towers and Manager Regional Services.

In 2007, Mr Hood joined CASA as Group General Manager for Personnel Licensing Education and Training, prior to moving to Brisbane to lead the General Aviation Group. In 2009, he was appointed Executive Manager of the Operations Division. In April 2012, he took on the role of Program Director for the newly established Operations Regulations Implementation Division.

Role
Operations Regulations Implementation is responsible for the development, planning and oversight of the regulatory implementation program.

Now remembering that HVH was both the ultimate executioner in the DJ embuggerance case while at the same time the designated liaison officer schmoozing the FAA IASA audit team (till their return in April 2010), the following Oz Flying article on McComic's 1st deckchair shuffle in April 2010 provides some intriguing dots begging to be joined:

Quote:...The restructure stems from organisational improvements the regulator commenced in 2009.

At the top of the list, Terry Farquharson has been appointed acting Deputy Director of Aviation Safety, where he’ll support Director of Aviation Safety, John McCormick, in a range of strategic and executive functions. Farquharson will also be directly responsible for a number of areas including accident investigation liaison, the CASA safety management system and Australia’s state safety program.

As part of the restructure, CASA has created the new position of Associate Director of Aviation Safety, which has been given to CASA’s former executive manager, legal services, Jonathan Aleck. Aleck will work with Deputy Director Farquharson to oversee the further development of regulatory and governance policies and practices.

The final changes see Greg Hood appointed as executive manager, operations; Peter Fereday as executive manager, industry permissions; and Gary Harbor as executive manager, corporate services.

McCormick said the changes will form the basis for the further enhancement of safety and regulatory capabilities into the future.

“We now have a strong and focussed leadership team in place which is committed to the goals and priorities which have been established for CASA and its workforce,” said the CASA boss.  “Senior managers and staff alike understand the need to deliver on CASA’s core activity of regulating aviation safety, while strengthening safety oversight and surveillance and completing regulatory reform.  

“At the same time we are continuing to work on developing more robust governance procedures and practices.”

On another note, CASA has released its latest corporate plan, setting out priorities and initiatives for the next three years.

Goals established in the plan include:
* An enhanced focus on regulating aviation safety;
* Enhanced governance and operational efficiency; and
* Enhanced relationships with key aviation participants.

In realising these goals the regulator says it will strengthen its specialist surveillance staff, determine key safety risks through analysis of data, actively manage delegates and authorised persons to ensure ongoing competence and compliance, take a proactive approach to the shortage of skilled aviation staff, review new regulations and develop and refine appropriate enforcement strategies. Other initiatives cover continuing airspace reform and safer management of flight approaches to aerodromes.

Say what you will about McCormick, but he's clearly keeping busy in the job.

Read the full CASA corporate plan here

Read more at http://www.australianflying.com.au/news/casa-restructures-leadership-team#YX2HwOPdp6wK8Q0d.99

   
Now fast forward to April 2012 where apparently HVH's job description changed and he became the.. 

..Program Director for the newly established Operations Regulations Implementation Division..

At the same time he mysteriously departed the scene (MIA) as the ultimate executioner/decision-maker in the DJ embuggerance case:

Quote:

---

  
Less than 12 months later (again seemingly inexplicably) HVH leaves CASA to return to ASA...

Via Oz Flying:

Quote:
Greg Hood has left CASA for a position at Airservices Australia, (CASA)

Greg Hood Resigns from CASA
31 January 2013

A key member of the CASA executive team, Executive Manager Greg Hood, is to leave CASA and return to Airservices Australia.

No date has been set for Hood's departure, but CASA has described it as "imminent". His new position at AsA will be as General Manager, Demand and Capacity Management.

In announcing the move, CASA Director of Aviation Safety John McCormick said: "Greg has been an integral part of CASA’s Executive Team over the last six years and I have personally valued his contribution, energy and enthusiasm and I know his management and leadership capabilities have significantly benefited CASA."

Greg Hood is highly thought-of within the general aviation community as a champion for GA, and it is expected his expertise will be missed at the regulator.

Read more at http://www.australianflying.com.au/news/greg-hood-resigns-from-casa#27lseOrg87IhhbIh.99

In addition to the above I would also like to add in the following 2017 FOI released document: https://auntypru.com/wp-content/uploads/2017/04/Dominic-James-documents-with-redactions-1.pdf

This document, in particular the email chain, IMO perfectly highlights the truly vicious, vindicative and vexatious, Big-R Regulator embuggerance campaign that was launched against Dom James, ably led by the former Sydney Office CASA Regional manager and psychopath Roger Chambers...  

However, what this document also provides is strong evidence of HVH's self-serving complicities, as the former decision maker in the regulator enforcement actions inflicted on DJ.

Extract: 



Note that HVH would appear to be more concerned in the fact that McComic was interested and offering his opinion/views on the subject of the proposed enforcement action of DJ, rather than being an independent and open minded decision maker on an issue that was potentially to have a profound impact on a young pilot's career...FFS!   

Much MTF on the corrupt and illegitimate award of the HVH GONG (AO) - 

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RE: The search for investigative probity. - Peetwo - 02-12-2023

Sanity prevails - the Adults have arrived?? - 

Via Popinjay central:

Quote:ATSB welcomes US team assisting 737 large air tanker investigation

The Australian Transport Safety Bureau (ATSB) has welcomed investigators from the United States to assist in the transport safety investigation into Monday’s large air tanker accident in Western Australia, in line with long-established international protocols.

The Boeing 737-300 was modified by the operator for aerial firebombing, and had conducted retardant drops in the Fitzgerald River National Park when it collided with terrain. Thankfully, both aircrew were able to self-extract from the aircraft without serious injuries before the aircraft was consumed by a post-impact fire.

ATSB transport safety investigators began arriving on site on Wednesday, staging from Hopetoun, to commence the on-site phase of the investigation.

On Friday they welcomed a team of six investigators from the National Transportation Safety Board (NTSB - the US accident investigation agency and equivalent to the ATSB), the Federal Aviation Administration (FAA - the US aviation regulator) and Boeing.

“We are pleased to welcome to Australia our colleagues from the NTSB, FAA and Boeing,” said ATSB Chief Commissioner Angus Mitchell.

“Boeing’s in-depth technical and operational knowledge of the 737, and the NTSB’s and FAA’s experience in investigating large aircraft accidents, will be of valuable assistance to the ATSB as we progress this investigation.”

Mr Mitchell noted that the international standards and recommended practices for conducting and cooperating on aircraft accident investigation are set out by the International Civil Aviation Organization’s Annex 13.

Under those provisions, as the United States was the state of design, manufacture and registration of the 737, the NTSB has appointed an accredited representative to the ATSB’s investigation, with the FAA and Boeing as technical advisors to the NTSB.

“While the investigation is the responsibility of the ATSB, we welcome the important contributions the NTSB, the FAA and Boeing will make.”

Mr Mitchell noted that international accident investigation agencies regularly work closely together, to assist each other with their investigations, and to share knowledge on best practice for conducting transport safety investigations.

“The ATSB enjoys close working relationships with our counterpart agencies across the globe. The assistance we can provide each other regularly leads to meaningful improvements in transport safety, worldwide.”
 
Date
11/02/2023

Hmm...I don't get the impression that old mate Popinjay had a heads up that the Adults were on their way??  

And what do we get, via Accidents Domestic - :

(02-11-2023, 10:40 AM)Peetwo Wrote:  Hold the bucket!! -  Popinjay to the rescue (AGAIN)?? 

Courtesy 9 News Oz, via Youtube:

 

Hmm...wonder how much he payed Karl for that appearance?? 

MTF...P2 

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RE: The search for investigative probity. - P7_TOM - 02-13-2023

Idle, uninformed speculation – from the pub..

6th @ 16:16 (LMT) - 737 event.. In Los Angelese – its late 2116 o'clock (+/-).

11th  ATSB Welcome etc.'/ meanwhile Angus on Ch 9 (blah blah).

So. just for fun; lets say the USA first notion of the event was – what? 0700 LMT – West coast.

Now, for the sake of idle speculation in the Pub; lets consider not just the the logistics; but the USA crew which arrived. NTSB (Wow) – FAA and Boeing. I'd call that a top deck crew, particularly the NTSB participation. Despite the platitudes and pleasantries – IMO, ATSB have been relegated to drinks at half time – (damn right too). 

But, for the sake of the conversation lets consider the 'time-line'. Six fellahin, fast asleep (USA time) – phone rings - “pack a bag, you're off to Australia (mate). So wherever these blokes are; shower, shave, pack a bag and book a flight to the staging point, from wherever they are located. Drive to airport, pick up ticket and catch the next flight to LA. Average that out for time – allow what? - an hour from call out to airport; allow 30 minutes from parking to ticket collection; allow 30 minutes through security; allow 30 minutes for boarding and assume one flight every hour hour to LA. It would take at least 3 hours, plus the flight time to actually arrive in LA. (Unless all six lived there, but even so – its still half a day to get to the next available international flight – and all six need to be on that flight to arrive 'mob handed'.  Then there is a 15 hour flight to Sydney or 16 to Melbourne; customs to clear etc (add a hour + at least six hours to get to Perth – provided there was a convenient connection with seats available.

Assume it took a whole day to arrange diplomatic approval (NTSB need that) assume it took another day to get everyone to one place; add another day to get to destination; and then, wonder why these guys moved in so very quickly with so much inconvenience and (NTSB) diplomatic approval.

No prizes for this – the Wee Bearded Popinjay is touting for airtime and glory, with NDI of what was approaching.– Meanwhile 'the grown ups' declared 'no-way' and arrived in bloody short order, to be sure (to be sure) 'things' were 'done right'.

I'm just surprised they weren't welcomed with a 'smoke ceremony' and given an approved dictionary detailing 'how' to address the locals 'correctly'.

These Americans are professionals; qualified, articulate, rapid, informed, knowledgeable; and, bet the bridge to a brick; will not take too much in the way of 'pony-pooh' from those who claim status from delving deeply into bird strikes while ignoring systemic problems related to 'mid-air' collisions.

Anyway - Welcome to the Land of Oz gentlemen; nice to see 'ya all'. Ignore my dribble – as idle Pub speculation. But well done anyway..

## - Butting in (sorry) - Please don't forget the 'location' of the Port (#1) Left engine = big questions right there methinks. L&K - 'K'....

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RE: The search for investigative probity. - Peetwo - 02-16-2023

CHALK & CHEESE: Nepalese AAIC release preliminary report - 

Via Linkedin:

Quote:Fatal accident of the ATR 42 registered 9N-ANC operated by @FlyYeti occurred on 15/01/23 / Preliminary report published by the Nepalese authorities in charge of the investigation. The BEA is participating in the investigation. https://lnkd.in/eG8Dkus9

&..



Ref: https://auntypru.com/wp-content/uploads/2023/02/343.pdf

So here we have a 3rd world country (backed by the French BEA) that release a factually accurate preliminary report within the 30 day ICAO Annex 13 requirement and in the process they issue a safety recommendation to the Nepalese CAAN (Nepal aviation safety regulator):

Quote:INTERIM SAFETY RECOMMENDATIONS

3.1 The Aircraft Accident Investigation Commission has recommended the following interim safety recommendation: The CAAN should conduct a comprehensive study to determine the appropriate flight path that allows the criteria for a stabilised visual approach to be met, taking into consideration of the simultaneous operations at both VNPK and VNPR airports before resuming visual approach on Runway 12 of VNPR.

       

Meanwhile here in Oz...(crickets)...on??

https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2022-067

&..

https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2022-068

&..

 https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-001

&..

 https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-002

&..

https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-004

&..

https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-005

Hmm...but we did get this absolute load of bollocks...

Quote:Flights land at Darwin with reduced landing distances available after misinterpreted NOTAMs



Key points

• Flight crews of two separate 737 flights misinterpreted NOTAMs at Darwin Airport and believed a displaced threshold was in operation for runway 11;
  
• Both crews conducted displaced threshold landings on runway 11, unnecessarily reducing available landing distance;
  
• Incidents highlight the critical importance NOTAMS can have for flight planning.
  

Two 737 passenger flights landed at Darwin Airport in September 2021 with unnecessarily reduced landing distances available to them after their flight crews misinterpreted NOTAMs detailing that a displaced threshold was in place due to runway works.

The incidents occurred on two flights operated by Virgin Australia Boeing 737-800s: the first on 3 September 2021, from Melbourne to Darwin, the second on 19 September 2021, from Brisbane to Darwin.

On both occasions, during pre-flight briefings, flight crews misinterpreted a NOTAM (notice to airmen) for Darwin Airport. The NOTAM stated that runway 29 (for landing from the east) had a displaced threshold of 765 metres due to works in progress and that the eastern end of the runway was not available due to the works.

Landing from the west on runway 11, however, did not require using the displaced threshold, although the landing distance available, due to the runway works at the eastern end, was reduced to 2,670 metres.

“On both occasions, the flight crews misinterpreted the NOTAM and conducted unnecessary displaced threshold landings, reducing the available runway for their landings.”

Both aircraft landed without incident.

“These incidents highlight the critical importance that operational information in a NOTAM can have for the planning and conduct of a flight,” ATSB Director Transport Safety Stuart Macleod said.
“Misinterpretation of NOTAM information can significantly affect flight safety.”

In addition, Mr Macleod noted correct and complete readback of air traffic control clearances are important to confirm information has been received and understood.

“Readbacks provide a valuable defence to detect and correct errors such as occurred during these incidents,” he said.

“Flight crews are also encouraged to seek clarification from air traffic control when there is uncertainty or ambiguity about the condition of a destination, such as a displaced threshold.”

After the first incident, Virgin Australia updated their Flight Crew Operational Notice for Darwin Airport. It then modified it further after the second incident, to specifically highlight the displaced thresholds.

Read the report: AO-2021-037: Reduced landing distance available involving Boeing 737 aircraft VH YIS and VH YFC Darwin Airport, Northern Territory on 3 and 19 September 2021

Publication Date
14/02/2023

MYF...P2  [/size]

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RE: The search for investigative probity. - Peetwo - 02-23-2023

Chalk and a mouldy Swiss Cheese??

Not Aviation related but I note the following NTSB social media release yesterday:

Quote:

An aerial view of the Norfolk Southern freight train derailment in East Palestine, Ohio captured on Feb. 5. (Source: NTSB)

NTSB Issues Investigative Update on Ohio Train Derailment

2/14/2023

WASHINGTON (Feb. 14, 2023) — The NTSB investigation of the Feb. 3 Norfolk Southern freight train derailment in East Palestine, Ohio is ongoing.

On Feb. 3, at approximately 8:54 p.m., local time, eastbound Norfolk Southern Railway, general merchandise freight train 32N, derailed on main track 1 in East Palestine, Ohio. As a result of the derailment, 38 rail cars derailed and a fire ensued which damaged an additional 12 cars. There were 20 total hazardous material cars in the train consist—11 of which derailed. A list of what the derailed rail cars were carrying is available online. There were no reported fatalities or injuries. 

NTSB is conducting a safety investigation to determine the probable cause of the derailment and issue any safety recommendations, if necessary, to prevent future derailments. The NTSB can also issue urgent recommendations at any point during the investigation. All questions regarding the safety investigation should go to NTSB. While emergency response will be a factor in the investigation, NTSB is not involved in air monitoring, testing of water quality, environmental remediation or the evacuation orders.

Questions on environmental issues should be referred to the Environmental Protection Agency. Learn more: East Palestine Train Derailment - EPA OSC Response.

Parties to the NTSB investigation provide technical assistance. They include: U.S. Department of Transportation’s Pipeline and Hazardous Materials Safety Administration and Federal Railroad Administration, Ohio State Highway Patrol, the Village of East Palestine, Norfolk Southern Railway, Trinity Industries Leasing Company, GATX Corporation, Brotherhood of Railway Carmen, International Association of Sheet Metal, Air, Rail and Transportation Workers and Brotherhood of Locomotive Engineers and Trainmen.

NTSB continues to work with the investigative parties to determine what exactly caused the derailment and to evaluate the emergency response efforts.

NTSB investigators have identified and examined the rail car that initiated the derailment. Surveillance video from a residence showed what appears to be a wheel bearing in the final stage of overheat failure moments before the derailment. The wheelset from the suspected railcar has been collected as evidence for metallurgical examination. The suspected overheated wheel bearing has been collected and will be examined by engineers from the NTSB Materials Laboratory in Washington, D.C.

The tank cars are currently being decontaminated. Once the process is complete, NTSB investigators will return to Ohio to complete a thorough examination of the tank cars.

The vinyl chloride tank car top fittings, including the relief valves, were removed and secured in a locked intermodal container pending an NTSB examination. Once the fittings are examined by NTSB investigators, they will be shipped to Texas for testing, which will be conducted under the direction of the NTSB.

NTSB has obtained locomotive event recorder data, forward- and inward-facing image recording data and wayside defect detector data. NTSB investigators continue to review documentation, event recorder data and perform interviews. A preliminary report is expected to publish in two weeks.

While on scene, NTSB Member Michael Graham hosted two press briefing on Feb. 4 and Feb. 5, which are available on NTSB’s YouTube channel. B-Roll is also available on YouTube.

Editor’s note: An earlier version of this release indicated 10 hazardous material railcars were part of the derailment. The actual number is 11.[/size]

To report an incident/accident or if you are a public safety agency, please call 1-844-373-9922 or 202-314-6290 to speak to a Watch Officer at the NTSB Response Operations Center (ROC) in Washington, DC (24/7).

 
Compare that to this bollocks WOFTAM ATSB/OTSI rail investigation: https://www.atsb.gov.au/publications/investigation_reports/2023/report/ro-2023-002

Quote:Summary

An investigation has commenced into the collision and derailment of two trains in Port Botany on 13 January 2023.

At approximately 0605, Pacific National train 1150 (operated by Railtrain Services) and QUBE Logistics train T296 (operated by Sydney Rail Services) collided and derailed during a propelling movement. Both trains derailed with the rear of train 1150 coming to rest against a nearby building. There were no injuries but there was significant damage to both trains and local rail infrastructure.

This investigation is being led by the NSW Office of Transport Safety Investigations (OTSI). OTSI conducts rail investigations in NSW on behalf of the ATSB under the Transport Safety Investigation Act 2003.

Following the incident, OTSI deployed two investigators to the derailment site and requested further information from the involved parties. After completing preliminary enquiries, it was considered by OTSI that a broader safety benefit may result from further investigation. In collaboration with the ATSB, it was decided the investigation would be completed under the Transport Safety Investigation Act 2003. As part of the investigation OTSI has begun collecting evidence from involved and other interested parties to determine the factors contributing to the accident.

A final report will be released at the conclusion of the investigation. However, should a critical safety issue be identified during the course of the investigation, OTSI and the ATSB will immediately notify relevant parties, so that appropriate and timely safety action can be taken.

 
Like Chalk and a mouldy Swiss Cheese?? - You BET! 

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 02-24-2023

Chalk and a Mouldy Swiss Cheese: Part II 

Courtesy NTSB, via Youtube:


So the NTSB release their preliminary report less than 3 weeks after the East Palestine Train derailment disaster...

Meanwhile in a very strange and coincidental parallel, from Popinjay's Media HQ, we get this load of bollocks...

Quote:Inverleigh derailment investigation preliminary report released

---

Key points

• 16 of 55 wagons of a freight train derailed as it passed over a culvert near Inverleigh, Victoria;
  
• Heavy rainfall had been recorded in the area prior to the derailment, and an embankment supporting the track at the location collapsed;
  
• Transport safety investigation is ongoing.
  

A preliminary report has detailed factual information established in the early evidence collection phase of the ongoing investigation into the derailment of a freight train near Geelong, Victoria on the morning of 14 November 2022.

The transport safety investigation is being conducted by the Chief Investigator, Transport Safety, who conducts rail investigations in Victoria on behalf of the Australian Transport Safety Bureau.

The report notes that the freight train was travelling at about 80 km/h over a culvert near Inverleigh, west of Geelong, when 16 of its 55 wagons derailed.

Significant rainfall was recorded at Inverleigh in the 12-hour period prior to the derailment, and the embankment supporting the track at the location of the culvert collapsed.

The incident resulted in substantial track damage, and 16 destroyed wagons. There were no injuries.

“Since attending the derailment site and completing a site and train inspection, investigators have examined drainage in the waterway catchment area and commenced hydrology studies,” Chief Investigator, Transport Safety Mark Smallwood said.

“Investigators have also examined operational information, conducted interviews, and commenced collecting other relevant information.”

Mr Smallwood said investigation will further review the waterway catchment, weather warnings in the area, the effect of prior rainfall on soil moisture and catchment flow and culvert design, including capacity.

Investigators will also review maintenance of track infrastructure and train operation.

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, relevant parties will be notified immediately, so appropriate and timely safety action can be taken,” Mr Smallwood said.

Read the preliminary report: Derailment of freight train 4PM9 Inverleigh, Victoria, on 14 November 2022

Publication Date
24/02/2023

And that took nearly three and half months to produce?? - UDB!   

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-01-2023

More ATSB (Popinjay) WOFTAM reporting vs NTSB benchmark as World No.1 in TSI??

I note the following Popinjay HQ media blurb for a  interim report that took 4 months to produce...

Quote:Interim report outlines Cairns approaches below minimum altitude



Key points

• Two Boeing 737-800 aircraft descended below minimum altitude during approach into Cairns on separate flights in October 2022;
  
• ATSB’s interim report details information gathered in early evidence-collection phase of investigation;
  
• Investigation is on-going, with analysis and findings to be presented in final report at later date.
  

An Australian Transport Safety Bureau interim report details a pair of occurrences involving Boeing 737-800 passenger aircraft which descended below minimum altitude constraints on approach into Cairns Airport, in North Queensland, in October 2022.

The interim report aims to provide timely information, gathered in the early evidence collection phase of the investigation, which is on-going. It contains no analysis or findings, which will be detailed in the final report.

In each occurrence, flight crews (one Virgin Australia, the other Qantas) entered the same standard arrival (HENDO 8Y) and approach (RNP Y runway 33) into their flight management computers, ahead of a planned landing on runway 33 at Cairns. However, neither flight crew selected the required approach transition.

In both cases, when presented with the discrepancy by the flight management computer, flight crews resolved it by manually connecting the arrival waypoint HENDO to the intermediate approach fix waypoint noted on the approach chart.

“As an unintended consequence, this removed the 6,800 ft descent altitude constraint associated with the initial approach fix waypoint in each aircraft’s programmed flight path,” ATSB Director Transport Safety Stuart Macleod explained.

“In both occurrences, the aircraft therefore descended below that constraint, as well as the 6,500 ft minimum sector altitude in that segment of airspace.”

In both cases, air traffic control alerted flight crews of their low altitude. No terrain warnings were triggered in either occurrence.

“The first flight, on October 24, took place on a dark night, so the Virgin Australia flight crew conducted a go-around, and then landed without further incident,” Mr Macleod said.

“The second flight, on October 26, occurred in daylight under visual conditions, so the Qantas flight crew was approved for a visual approach by air traffic control, and landed without further incident.”

To date, the ATSB has interviewed the flight crews, examined recorded flight data, reviewed air traffic control audio and surveillance data, and reviewed operator and air traffic control procedures.

The interim report notes both operators have already taken steps to provide flight crews with further guidance, relating in particular to approaches where the selection of an approach transition is required.

“Going forward, the ATSB’s investigation will include further review and examination of the evidence gathered, as well as instrument procedure and waypoint naming processes and standards, and arrival and approach chart information and presentation,” Mr Macleod said.

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so that appropriate and timely safety action can be taken,” Mr Macleod concluded.

Read the report AO-2022-051: 

Flight below minimum altitude occurrences, 40 km south of Cairns Airport, Queensland on 24 and 26 October 2022

Publication Date
28/02/2023

I also note that along side that bollocks media blurb it states this:

Quote:Final report

AO-2022-051 Flight below minimum altitude occurrences, 40 km south of Cairns Airport, Queensland on 24 and 26 October 2022

-   

Perhaps the IIC and the investigation team did intend for this to be Final Report and that further investigation would be discontinued? Especially when you consider the following from the (3 month overdue) interim report...

Quote:Safety action

The ATSB has been advised of the following proactive safety action in response to these occurrences.

Virgin Australia

Virgin Australia updated flight crew operation notice information for Cairns with detailed guidance for the conduct of the HENDO 8Y arrival and RNP Y runway 33 approach. Virgin Australia also provided guidance to all Boeing 737 flight crew for the conduct of arrivals and approaches where the selection of an approach transition was required.

Qantas

Qantas issued an internal notice to flight crew providing guidance for the conduct of arrivals and approaches where the selection of an approach transition was required.

In other words the FMC flight path 'discontinuity' error that led to the two incidents briefly flying below min altitude, has been fully addressed/mitigated by both airlines inside their SMS, probably about a week after the incidents occurred. Yet the ATSB is continuing with the investigation - FFS!

Meanwhile, at the recent Estimates hearing, Popinjay begged limited resources and the Ministerial SoE as reasons why the ATSB did not investigate the Kybong mid-air collision:

Quote:Senator McKENZIE: Recreational Aviation Australia recently declined to investigate a fatal accident in Kybong, Queensland due to the burden these investigations were putting on the organisation. Has the bureau had any discussions with Recreational Aviation Australia about their resourcing concerns?

Mr Mitchell : I've certainly had discussions with RAAus over that particular incident and others. There have been a number of incidents. I think, in that particular sector: there are anywhere between six to 10 fatal accidents, generally, per year. The recent decision by RAAus not to investigate there is certainly one for them. In terms of our priority list, our priorities lie with general greatest benefit for the travelling public, and sport, recreational and experimental aircraft are lower down on our list.

Senator McKENZIE: That significant service is now no longer to support police and coroners into the future. Recognising the resourcing concerns, have you asked the minister for more resources in the upcoming budget round?

Mr Mitchell : We are certainly in discussions with the department around our resourcing and expectations. Our expectations need to be matched with resourcing, so it has been a long established position that we do not investigate in that recreational space, and that has been since 2014, since the Forsyth review was conducted.

Senator McKENZIE: So the minister would actually have to change the expectations for you to actually do that—is that your argument here?

Mr Mitchell : I think it would be a combination of changing expectations or funding and potentially—

Senator McKENZIE: Let's hope the minister funds you appropriately so you can assist Recreational Aviation Australia with their coronial assistance. And my apologies we couldn't spend more time, but I'll have questions on notice. Thank you, Mr Mitchell.

 

Talk about 'discontinuity' - 

Meanwhile I note the following blurb from the NTSB's 'Office of Aviation Safety':

Quote:The mission of the Office of Aviation Safety (AS) is to:

1. Investigate all civil domestic air carrier, commuter, and air taxi accidents; in-flight collisions; fatal and nonfatal general aviation accidents; and certain public-use aircraft accidents; uncrewed aircraft systems accidents; and commercial space mishap accidents.
   
2. Participate in the investigation of major airline crashes in foreign countries that involve U.S. carriers or U.S.-manufactured or -designed equipment to fulfill U.S. obligations under International Civil Aviation Organization agreements, and
   
3. Conduct investigations of safety issues that extend beyond a single accident to examine specific aviation safety problems from a broader perspective.
   

AS has the responsibility for investigating domestic aviation accidents and incidents (about 1,750 annually) and for proposing probable cause for the Board's approval. In conjunction with other offices within the NTSB, the office also works to formulate recommendations to prevent the recurrence of similar accidents and incidents, and to otherwise improve aviation safety.

   
Finally, on the accidents overseas thread AP is covering the fatal PC12 medevac inflight break up accident investigation: PC12 fatal inflight breakup

Here is a MSM Youtube link (has to be viewed on Youtube) that covers some snippets from the NTSB media briefing on that tragic accident: https://youtu.be/PqBPgit8yK8

And this is the NTSB B-roll documenting the accident site:


Note the resources at the disposal of the NTSB include the FBI and working in conjunction with local authorities.

Considering the PC12 is the predominant a/c type used by our own RFDS, there will be many industry stakeholders interested in monitoring the progress of this investigation. I wonder how long it will take the NTSB to release an interim report??

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-04-2023

Popinjay record investigation completion; & Harfwit normalised deficiciencies?  

Via Popinjay HQ:

Quote:Changes underway after loss of separation after take-off from Sydney



Key points

• A loss of separation occurred between a Boeing 787 and an Airbus A330 shortly after take-off from Sydney Airport in September 2022;
  
• The standard instrument departure (SID) being used by both aircraft did not provide a positive method of providing separation assurance;
  
• Airservices Australia has advised of a redesign for the SID, but a timeframe for implementation is unknown, and the ATSB will continue to monitor.
  

The ATSB will monitor the planned introduction of a revised Sydney Airport standard instrument departure (SID), after a loss of separation occurrence involving two widebody airliners shortly after take-off last year.

On the afternoon of 28 September 2022, a Boeing 787-9, operated by British Airways, took off from Sydney’s runway 16R for a scheduled passenger service to Singapore.

Approximately three minutes later, an Airbus A330-200, operated by Qantas, departed the same runway for a scheduled passenger service to Cairns.

Both aircraft were directed to follow the same standard instrument departure (SID) routing, the DEENA 7 SID, for their respective climbs to 28,000 ft.

This SID required the aircraft to meet two separate conditions after take-off before turning to the north-west: they had to pass the DEENA waypoint, and they had to climb to at least 6,000 ft.

“Because aircraft have to satisfy two separate conditions prior to turning, there is no way to ensure aircraft will turn at the same location when conducting the DEENA 7 SID,” ATSB Director Transport Safety Stuart Macleod explained.

In the September incident, the trailing A330 was being used on a domestic flight, with a correspondingly lower fuel load and higher climb performance than it would have had for an international flight.

“The departure controller did not expect this, and instead expected the A330 to have a similar climb performance to the 787 it was following, thus remain behind it and turn at about the same location,” Mr Macleod said.

Instead, the A330 reached 6,000 ft as it passed DEENA, and began its turn about 20 km from the airport.
Meanwhile, the heavier 787 reached 6,000 ft some time after passing DEENA, and began its own turn about 25 km from the airport.

This meant the trailing A330 was turning inside the path of the 787, as they both climbed to the same flight level.

During the event, separation between the aircraft reduced to 2.4 NM laterally, and 600 ft vertically – below the required separation standards of either 4 NM laterally (for ‘heavy’ aircraft) or 1,000 ft vertically – before the controller advised the aircraft and separation was re-established.

The British Airways flight crew later advised they had received a traffic collision avoidance system (TCAS) traffic advisory during the event, and the first officer had subsequently visually identified the A330.

“Maintaining separation in high traffic terminal areas, such as Sydney, requires that both controllers and flight crews remain vigilant, maintain open communications, and use the available systems and tools to minimise the risk of errors,” Mr Macleod said.

“When sequencing departures, controllers should consider a number of factors, including how the flight duration (and the associated fuel load) will likely affect aircraft climb performance.”

The ATSB final report notes that, in the last decade in Australia, there have been eight loss of separation occurrences involving aircraft cleared on a SID, where a following aircraft has climbed faster than the preceding aircraft.

Of these, six were at Sydney, and five involved the DEENA 7 SID.

“Airservices Australia has advised the DEENA 7 SID has been redesigned to remove the two conditional requirements of the procedure,” Mr Macleod said.

“The changes are planned to be part of the first implementation package for Western Sydney International Airport, but as the timeframe for this implementation is unknown, the ATSB will continue to actively monitor this open safety issue,” Mr Macleod concluded.

Read the report: AO-2022-047: Loss of separation involving Airbus A330, VH-EBK, and Boeing 787, G-ZBKF near Sydney Airport, New South Wales on 28 September 2022

Publication Date
03/03/2023

Kudos for once to Popinjay's crew, 6 months to completion and publication of a final report would have to be an all time record?? 

"..in the last decade in Australia, there have been eight loss of separation occurrences involving aircraft cleared on a SID, where a following aircraft has climbed faster than the preceding aircraft.

Of these, six were at Sydney, and five involved the DEENA 7 SID.."

Hmm...



“..The changes are planned to be part of the first implementation package for Western Sydney International Airport, but as the timeframe for this implementation is unknown, the ATSB will continue to actively monitor this open safety issue,..”

Hmm...why so long?? - 

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-08-2023

Popinjay to the rescue - CHALK & CHEESE Part?? 

Via Accidents Domestic:

(03-08-2023, 07:47 AM)Peetwo Wrote:  Popinjay to the rescue - 

Courtesy the other Aunty, via Youtube:

Plus: https://www.abc.net.au/news/2023-03-07/qld-gold-coast-sea-world-helicopter-crash-collision-explainer/102063520

P2 OBS (so far) - Quote apparently attributed to Popinjay: “The ATSB anticipates publishing a preliminary report detailing basic information gathered during the investigation’s evidence collection phase in approximately 6-8 weeks..."

I note that PJ was attributed to saying 'approximately' but the ATSB took a full 65 days and exceeded the ICAO Annex 13 30 day interim report requirement by 35 days.

The NTSB on the other hand took 12 days to complete the Kobe Bryant Calabasas CFIT chopper accident.

You now can compare the two preliminary reports:

1/ https://www.ntsb.gov/investigations/Documents/DCA20MA059-Investigative-Update.pdf

2/ https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-001 & https://www.atsb.gov.au/sites/default/files/2023-03/AO-2023-001%20prelim_0.pdf

I also note that there did not appear to be any serious fanfare, other than a short press statement, that accompanied the release of the NTSB preliminary report. Why? Probably because the NTSB Board believe the report speaks for itself...

Another OBS from the full ABC PJ presser is from 12:53 min, when asked questions on timelines etc for the investigation. PJ starts off by saying that "..this is defined as a systemic investigation..blah..blah.."

However on the header to the ATSB investigation webpage under the 'Investigation Level' it clearly states 'defined':



MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-09-2023

A WTD Headline? - 

From Popinjay HQ yesterday - this headline:

Weather diversion from Sydney Airport to an emergency alternate involving Qantas B787-9 VH-ZNJ, on 18 February 2023

Investigation link: https://www.atsb.gov.au/publications/investigation_reports/2023/report/ao-2023-009

Quote:

Summary

The Australian Transport Safety Bureau (ATSB) has commenced an investigation into the weather diversion from Sydney Airport to an emergency alternate airport involving Qantas B787-9, registered VH-ZNJ, on 18 February 2023.

During approach, the aircraft encountered moderate turbulence and high wind conditions and the approach became unstable. The crew conducted a missed approach and advised ATC of minimum fuel conditions. The crew diverted the aircraft to Williamtown where ground handling equipment was not sufficient for the aircraft size. The investigation is continuing.

A final report will be published at the conclusion of the investigation. Should any safety critical information be discovered at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

Remember that this was what occurred (weather wise) in Sydney on that day:

Ref news link: https://www.abc.net.au/news/2023-02-18/sydney-storm-outages/101994636 

Hmm...where to start with this one? 

Q/ Why has it taken nearly 3 weeks for 'Attributed to Popinjay' to decide to investigate? And why is the investigation level only listed as 'Short'? And why was this investigation slipped out with zero fanfare/media coverage and under the cover of the release of the Gold Coast midair prelim report? 

I'm not sure of the actual stats but I'd be surprised if I could count on more than 10 fingers the number of times a Qantas international aircraft has had to divert due wx to an 'emergency alternate' - 

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-10-2023

Addendum to last: How many minutes to bingo fuel??  

Found some media coverage on the QF28 diversion to Williamtown RAAF base, which suggests bizarrely that it is an acceptable practice for a Qantas international HCRPT airliner to conduct a missed approach into Sydney and then have to bolt to a 'emergency alternate' - WTD??   

Quote:"..During approach, the aircraft encountered moderate turbulence and high wind conditions and the approach became unstable. The crew conducted a missed approach and advised ATC of minimum fuel conditions. The crew diverted the aircraft to Williamtown where ground handling equipment was not sufficient for the aircraft size. The investigation is continuing..."

Via Simple Flying:

Quote:Qantas 787 From Santiago Forced To Divert Due To Sydney Storms

BY
MICHAEL DORAN
PUBLISHED FEB 20, 2023

Despite keeping passengers and crew safe, Qantas has been criticized for a diversion that saw a 787 sitting on the ground in Newcastle.



While Qantas has recently been in the news for all the wrong reasons, it seems the Flying Kangaroo is now being held responsible for the violent storms in Sydney on Saturday night that forced one of its aircraft to divert to Newcastle.

With the Boeing 787 unable to land in Sydney, the airline took the appropriate action and yet still copped a bucket full of criticism for keeping passengers and crew safe.

To start at the start, Qantas flight QF28 departed Chile from Santiago International Airport (SCL) at 14:22 on Friday. The flight was operated by a three-year-old Boeing 787-9 Dreamliner, registered VH-ZNJ with MSN 66074, and painted in the Qantas 100-year commemorative livery.

According to Flightradar24.com, it was due to touch down at Sydney International Airport (SYD) at 17:50 on Saturday, after a flight covering 11,363 kilometers (7,060 miles), which usually takes around fourteen hours.

Stormy Sydney prevents 787 landing

However, severe storms in the Sydney area forced several aircraft to be diverted, including this one from Santiago, the only international flight affected. The Dreamliner was diverted north to Newcastle, where it landed at Newcastle Airport (NTL), a regional center around 100 miles from Sydney.



While that kept the passengers, crew and aircraft safe, a report from news.com.au said that Newcastle Airport lacked the necessary facilities to accommodate and refuel the widebody, so it was, in effect, stranded for the night. The aircraft is configured to carry 236 passengers who, along with the crew, faced an uncomfortable night on top of enduring extreme turbulence during the flight.

There were no immigration services or accommodation immediately available, so passengers had to stay onboard for around seven hours while the aircraft sat on the apron. The news.com.au report said they were eventually allowed to leave the aircraft and spend the night in the terminal.

It's tough being an airline

As expected nowadays, social media lit up with criticism of Qantas, although it is difficult to see what else the airline could have done in the circumstances.

Ref link: https://twitter.com/OzziePatriot/status/1627068595120517121?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1627068595120517121%7Ctwgr%5E3fb7e72b954c195a9a87e07ce063e024fc448060%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Fsimpleflying.com%2Fqantas-787-santiago-divert-sydney-storms%2F

Quote:JFR
@OzziePatriot

Hey @Qantas why did a plane from Chile last night make an emergency landing at Newcastle airport late yesterday and is still there this morning? Passengers forced to sleep in terminal??? @nbnnews

@newcastleherald what excuses will be spun???

https://pbs.twimg.com/media/FpSBpa6akAMMJIr?format=jpg&name=small

In response, the airline released the following statement, thanking customers for their patience throughout the long, uncomfortable night.

Quote:"This included our flight from Santiago to Sydney which diverted to Newcastle. Qantas customer support team members travelled from Sydney to Newcastle to assist customers in the terminal through the night. We understand that this would have been a frustrating experience for our customers and an uncomfortable night and we thank them for their patience and understanding of the impact the storms had on flights into Sydney."

According to the Sydney Morning Herald, passenger John Myers described the flight as incredibly bumpy and that a crew member had said the turbulence was "extreme." He said:

Quote:"A lot of us have been on flights that were bumpy, but that was on another level. Some people were holding hands, and a few people were gripping on tight, there were a few gasps, but no screams."

Inflight catering to a new level

For the uninitiated, Australia's Newcastle is no New York, so finding food and refreshments for more than 200 people in the middle of the night is not an easy task. The report said that, in the early hours of the morning, the flight crew appeared with hamburgers and drinks for passengers sourced from the local McDonalds. Meyers put that into perspective by saying:

Quote:"It was lukewarm, and I'm not usually a Maccas fan, but I was hungry and desperate times call for desperate measures. By and large, people kept their cool, and it was good to see that the people at the pointy end weren't treated any differently to people in cattle class."

The 787-9 returned to Sydney on Sunday, with the Flightradar24.com data showing it landed at 10:22. While Qantas has had an unusually high number of turnbacks this month, diverting an aircraft that can't land safely is nowhere near a failure by any airline.

Of course, in situations like these, there are always things that could have been done differently, but overall it is hard to see how Qantas can be criticized for this one.

Hmm...so just for shits and giggles, what if on arrival Williamtown QF28 experienced the same or similar conditions that they experienced in YSSY and were forced to conduct another missed approach? Would they have been placed in a situation where they might have had to consider a controlled (powered ) ditching into Tilligerry creek; or Anna bay?    

MTF...P2 

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RE: The search for investigative probity. - Kharon - 03-11-2023

Let cool heads prevail.

Let us begin with the first line of the 'in Command' mantra; (paraphrased); in short 'get the bloody aircraft on the deck, in one piece as soon as practicable'. There are more elegant ways of expressing that; but when the whatsit hits the windmill and there are no trump cards left in the deck – you just do what it needful, save your own life; and, by default, the lives of all inboard and the ship...

The use of an 'emergency alternate' is not as dramatic as it seems at first encounter; it will be scripted somewhere within the bowels of 'the book' along with 'command discretion' - .  This flight would have had a constant flow of data over the 14 hours (+/-) duration: they would know in advance the state of play at Mascot, the storm would have been monitored on radar and (probably) any 'reports' from other aircraft; lots of information available on which to formulate a plan. The critical element would be the fuel on board; the calculation of fuel required. This would involve the 'burn' from top of descent; to a missed approach; this subtracted from the total available. This is what would have been planned for, should the worst case scenario eventuate.

Skilled, experienced crew; thunderstorm activity around the destination not an unusual situation – trained for and always carefully managed. The Sydney storm was a brute; the aircraft serviceable and a qualified crew operating; they gave it the one shot they had left in the tanks – missed out and diverted to the nearest aerodrome where a landing could be assured i.e. Williamstown. Not a preferred option; however, despite the lack of facilities for the passengers – given the alternatives – I'd say 'well done' that crew. Sure passengers tired, hungry and upset; but alive to enjoy the rest of their days. Such is life in the worst case scenario.

There is a rumour floating about (unsubstantiated) that the passengers could have been on the deck a bit earlier had the ATC been more situationally aware and expedited clearance as requested and required. I wonder how close the Skipper came to telling them to 'sod off' or cope with a Mayday. Had the Skipper got cranky and declared an emergency due to ATC being 'difficult' that would become a difficult question for ASA to answer. 

Nicely done that crew; tough day at the office and well worth a couple of hard earned drinks. Cheers.

Toot – toot.

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RE: The search for investigative probity. - Peetwo - 03-13-2023

Via VibbleVobble on Twitter...

Quote:Sydney Airport closed by summer storm and @Qantas QF28 was coming into land, but waved off and diverted to RAAF base in Newcastle. #qantas #sydneystorm @flightradar24

---

Plus:

Reopened ?. Lots of lightning and thunder around ⛈️ ?
#sydneystorm

And in reply to @VVoble:

Quote:@dez_blanchfield
·
Feb 19

#DezPhotoChallenge

Wild #summer #storm appeared over the the city at #sunset, moving in from the south & rolled north over the #harbour with one of the most astounding layered #cloud formations I’ve ever seen form over #Sydney.

#SydneyStorm shot from the #Cremorne ferry wharf.

Totally agree the QF28 crew did a stellar job under the circumstances...

As for the Harfwit crew???

MTF...P2

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RE: The search for investigative probity. - Peetwo - 03-21-2023

Dots-n-dashes to: "How many minutes to bingo fuel??" 

Just putting the dots up here for now, from this Senate recommendation...



To this blast from the past...


Hansard quote:

Quote:Senator NASH: You made a judgement call that it was those things that you have just referred to, but what concerns me is that chances are that pilot is not going to get in a plane and do that again. One of the bigger issues that has emerged, surely, is this fault line in the provision of information from New Zealand. That is a set of circumstances that, at any period of time, could happen again, obviously with a resultant, potential, dire, catastrophic consequence. You identified early those pilot issues as being the most important. Isn't that rather presumptive given that this other issue has virtually been completely overlooked?

Mr Dolan : I would differ with you on the question of the overlooking of that issue. We took the current provisions of the AIP and the current arrangements for the provision of weather information by air traffic services. Those provisions in the AIP clearly say, 'Principal responsibility is with the pilot to acquire weather related information, including forecasts.' There is some provision for air traffic services to proactively draw attention to the existence of an updated forecast, normally in the case where aircraft are within an hour of their intended destination.

Senator NASH: We had Airservices Australia in here only two days ago, admitting that the provision of weather information from New Zealand was an issue that they are now going to address through the Pacific forum, which they were not going to do until it was raised through this forum. But you are saying it is not an issue. So they are saying it is an issue and that they are going to address it, but you are telling us today that you do not see that it is an issue.

Mr Dolan : We see a broader issue, which is: what is the support that is provided to flight crews en route in terms of assessing their situation, getting access to weather and other related information, applying that to the management of their fuel and so on? This is in a context where we saw in the AIP something that very clearly said that it is the responsibility of pilots to obtain information necessary to make operational decisions and that pilots will not automatically receive routine TAF information showing deteriorating weather conditions if they are en route to a location. That was the status quo with Airservices, with New Zealand and, as we understand, with Fiji.

Senator NASH: That is extraordinary.

Also throw in the BOM session 2 days before and the full version of the Staibed in the Dark and Harfwit bollocks:

Quote:Senator XENOPHON: Can you explain that? I am just trying to get the context here. What are our international obligations in regard to the sharing of hazardous weather information with other air traffic service organisations?

Mr Harfield : We have a monitoring system where the Bureau of Meteorology obviously monitors a number of locations around Australia and within the jurisdiction of the airspace that we manage. When we get information provided that is of a differing nature from the forecast, such as a hazardous weather event or the SPECI information that you mentioned previously, that information is then sent to the control positions. It is then relayed to the particular aircraft based on certain parameters where the weather has changed. We call that a hazard alerting service. What we would do, for example, if an aircraft which had a terminal area forecast for Sydney was flying between Melbourne and Sydney and the weather conditions rapidly changed is issue a hazard alert and notify all aircraft going to that destination of the change in circumstances.

From the Pelair Mark II ATSB final report:

Quote:

• reviewing documentation from the air traffic services providers in Fiji and New Zealand about their policies and procedures for the provision of flight information, and how these were applied during the accident flight
  

"...During the flight, the weather conditions at Norfolk Island deteriorated below the landing minima. Air traffic services in Nadi and Auckland did not provide the flight crew with all the information that should have been provided. In addition, the flight crew did not request sufficient information prior to passing the point of no return (PNR), and the captain did not use an appropriate method for calculating the PNR. Related to these actions, the operator’s risk controls did not provide.."

Hansard link - HERE

Hmm...apparently the above was the sum total of the ATSB's findings in regards to the Senate recommendation IE there was no latent safety issues discovered and needing to be addressed...  

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-25-2023

Beaker's legacy and the 6 year YMEN DFO crash cover-up??  

To begin there is still no indication on when the Popinjay YMEN DFO approval process investigation will be completed...  

Quote:..Extensive DIP submissions were received during November. The ATSB is reviewing the evidence in response to the submissions. Consistent with ATSB processes, and to ensure the veracity of any findings, some further engagement will be required with those parties before the investigation is finalised.

An update on timing for completion of the investigation will be provided at the start of 2023 after the ATSB has been able to complete necessary engagements with Australian and international DIPs...

  
Next and related, here is a blast from the past from almost 11 years ago:


Trolling through the records from the May 2012 RRAT Budget Estimates I came across a disturbingly revealing Beaker reply to a committee correspondence query:

Quote:4. Correspondence to Mr Martin Dolan, Chief Commissioner, Australian Transport Safety Bureau, in relation to evidence given at Senate Estimates on Wednesday 23 May 2012. 

(PDF 49KB)
Mr Dolan's response (PDF 290KB)

The following extract from Beaker's reply is truly remarkable when you consider the YMEN B200 DFO crash that occurred almost 5 years later: 



Talk about beyond all Reason - UDB!! 

   
MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-31-2023

Further proof the ATSB is totally dysfunctional?? - 

Via Popinjay HQ, another totally pointless 'Short' investigation began today, six days after the non-event...  

Quote:Pressurisation fault involving SAAB 340, VH-VEZ, near Goulburn NSW on 25 March 2023

Summary

The Australian Transport Safety Bureau (ATSB) is investigating a pressurisation fault involving SAAB 340, VH-VEZ, near Goulburn New South Wales, on 25 March 2023.

During the pre-flight inspection, the crew identified missing trim from the cabin door. During climb, the aircraft did not pressurise as expected and the crew conducted a precautionary descent. The engineering inspection identified a door seal failure. The investigation is continuing.

Should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

  
Hmm...you do have to wonder what the crew were thinking when they decided not to U/S the aircraft when they noticed the missing door trim?? However wouldn't that be a matter that would have been captured by the company SMS and not anywhere near the threshold for a ATSB investigation? - 

MTF...P2 

PS I note that the ATSB is bizarrely (or maybe wishfully) predicting that the final report (or maybe the preliminary report) will be completed by 18/08/23??

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RE: The search for investigative probity. - Peetwo - 04-05-2023

Continued: ATSB totally dysfunctional and non-compliant with ICAO Annex 13?? - 

Yesterday, without very little fanfare, this week's Director Transport Safety Stewie MacLeod put out the following statement in regards to the release of a 'Short' investigation final report into an incident that occurred 2 years, 7 months & 21 days ago...  
 

Quote:Fatigue cracks identified in fanwheel of mustering accident R22



Key points

• Investigation identified fatigue cracking in R22 helicopter fanwheel, which probably led fanwheel to break-up during 60 ft hover;
  
• Break-up created imbalance which likely led forward drive belt to migrate from drive sheaves, causing loss of rotor drive and collision with terrain;
  
• The ATSB reminds pilots and maintainers to pay particular attention to the installation, maintenance, and ongoing inspection of critical components of R22 and R44 drive systems, and to report all defects to CASA.
  

An Australian Transport Safety Bureau investigation found evidence of fatigue cracking in the fanwheel assembly of a Robinson R22 helicopter, which collided with terrain after a sudden loss of rotor drive at a low altitude.

On 16 August 2020, the pilot and sole occupant of an R22 was conducting mustering at a property near McArthur River Mine in the Northern Territory.

While hovering 60 ft above the ground, the helicopter experienced a sudden loss of rotor drive, resulting in a rapid loss of height and collision with terrain. The pilot sustained serious injuries, and the helicopter was substantially damaged.

An ATSB investigation found evidence of fatigue cracking in the helicopter’s cooling fanwheel outer support ring, and in the welded region of two vanes of the fanwheel assembly.

“These fatigue cracks probably weakened the fanwheel structure sufficiently for it to break-up in flight,” ATSB Director Transport Safety Stuart Macleod said.

This caused an imbalance which likely led the forward drive belt to migrate off the drive sheaves, resulting in a loss of rotor drive.

The ATSB’s report notes cracking of Robinson fanwheels in the vane weldment has been identified to occur in a limited number of the R22 fleet, however this was the first instance where the cracking had progressed to the point of in-flight failure.

“The circumstances of this accident are an important reminder for pilots and maintainers to pay particular attention to the installation, maintenance, and ongoing inspection of critical components of the drive systems of both Robinson R22 and larger R44 helicopters,” Mr Macleod said.

The ATSB’s final report also notes that many Robinson operators are aware that cracking can occur at the welded regions of the cooling fanwheel.

“This awareness, however, is not reflected in CASA’s Defect Reporting Service data, suggesting such instances are under-reported,” Mr Macleod said.

“The non-reporting of defects prevents the sharing of knowledge to the wider aviation community and the identification of emerging issues.

“Defect reporting benefits the aviation industry. It allows CASA to create a database, which is used to identify trends in design and maintenance reliability of aircraft systems and components and is a publicly accessible service.”

Additionally, while not a contributing factor in the accident, the ATSB found the details associated with the helicopter’s emergency locator transmitter (ELT) had not been updated since the helicopter was recently purchased by the operator.

This meant that when the transmitter automatically activated during the accident sequence, the Joint Rescue Coordination Centre was delayed in confirming an accident had taken place.

“Fortunately, this accident was reacted to quickly by others involved in the mustering,” Mr Macleod said.

“But where an aircraft is operating alone, any delay to the search and rescue response could be critical to occupant survival.”

Aircraft operators should ensure details associated with emergency locator transmitters are current. (All 406 MHz ELTs are required to be registered with the Australian Maritime Safety Authority.)

Read the report: Rotor drive system failure and collision with terrain involving a Robinson Helicopter Company R22, VH-YMU 44 km south of McArthur River Mine Airport, Northern Territory on 16 August 2020 | ATSB

Publication Date
04/04/2023

 
Note that this 'Short' investigation did not include any preliminary report, there was however this (new addition) to the FR as an apparent explanation on why the decision was made to limit the scope of the investigation...  

Quote:The investigation

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, a limited-scope investigation was conducted in order to produce a short investigation report, and allow for greater industry awareness of findings that affect safety and potential learning opportunities.

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 04-13-2023

Popinjay to the rescue: Broome R44 in flight breakup FR released? 

Mr Attribution still ATCB Media rep for this week? Via PJ HQ: 

Quote:ATSB releases Broome R44 helicopter accident investigation final report



Key points

• An overstress fracture, shortly after take-off, led to the separation of the tail rotor gearbox from the helicopter, and the subsequent separation of the aft tail section;
  
• Pilots had previously reported experiencing vibrations in the helicopter’s tail rotor pedals;
  
• Investigation highlights that aircraft should not be returned to service until known issues are rectified, and that a conservative approach to troubleshooting mechanical issues and return to service should be taken to minimise risk
  

An ATSB investigation into a fatal helicopter accident that occurred shortly after take-off from a yard in a Broome industrial suburb highlights the crucial importance of pilots formally declaring their helicopters to be unserviceable when the source of unusual vibrations has not been identified and rectified.

On 4 July 2020, a Robinson R44 helicopter with a pilot and three passengers on board conducted a vertical departure from an industrial property at Bilingurr, 3 km north of Broome Airport, to conduct a private joyflight. As the helicopter climbed clear of obstacles and transitioned to forward flight, witnesses on the ground heard a loud bang, and observed the helicopter’s empennage and tail rotor system separate and break away.

The helicopter continued to climb and commenced rotating to the right with increasing angular velocity, before control was lost, and it impacted a road on its right side. The pilot and the passenger, who were seated on the right side of the helicopter were fatally injured. The two passengers who were seated on the left side of the helicopter sustained serious injuries.

“The ATSB found that an overstress fracture of the tail rotor gearbox’s input cartridge occurred following a period of vibration in the helicopter’s tail rotor pedals,” said ATSB Chief Commissioner Angus Mitchell.

“This overstress fracture, shortly after take-off, led to the separation of the tail rotor gearbox from the helicopter, and the subsequent separation of the aft tail section.”

The ATSB’s investigation report notes the helicopter’s two previous flights were conducted by two separate pilots (including the accident pilot, who was also the helicopter’s owner), who both reported experiencing vibration in the helicopter’s tail rotor pedals.

In response the owner requested that their local approved maintenance organisation assess the vibration. Engineers from the maintenance organisation assessed the helicopter in the yard on the afternoon of 3 July. They found the tail rotor balance to be within limits, and a close inspection of the tail cone, tail rotor and empennage of the helicopter detected no issues. Further, no vibration in the pedals was detected during ground running of the helicopter in the yard.

Nonetheless, the maintenance engineer reported wanting a pilot to fly the helicopter to determine if the reported vibration in the pedals was detectable in flight.

However, while the requirement for a maintenance check flight was not recorded on the helicopter’s maintenance release, the owner of the maintenance organisation advised the ATSB that they advised both the owner and the pilot who first detected the vibrations of the requirement to fly the helicopter to provide more information. Friends and family of the owner of the helicopter stated that no request for further flight was made.

“As the vibration was reported to only occur in flight, and no defect was identified, it was reasonable to have concluded that the problem may still be present,” said Mr Mitchell.

“As such, the safest next step, which is recommended by the helicopter manufacturer, would be to conduct a graduated flight check of hovering then re-inspection. Preferably, this would be with only a prepared pilot on board.

“Instead, the next flight, during which the accident occurred, involved the conduct of a high‑power towering take-off from a confined area with 3 passengers on board.”

The investigation report notes that the registered operator of an aircraft has ultimate responsibility for its airworthiness.

“This accident demonstrates the importance of following a conservative troubleshooting process that minimises risk.”

Mr Mitchell noted that while the source of the loading that led to the overstress fracture was not conclusively determined, the pilot’s operating handbook for the R44 helicopter states that the onset of unusual vibrations can indicate impending failure of a critical component.

“The pilot’s handbook states that pilots should land as soon as possible and formally declare the helicopter unserviceable.

“Crucially, the helicopter should not be returned to service until the source of the vibration, both on the ground and airborne, has been found and rectified.”

Mr Michell also noted that private pilots do not, unlike commercial and airline pilots, have the benefit of regular flying and frequent training and checking.

“The ATSB recommends private pilots to not rely on the minimum training and checking and training currency requirements to keep safe, and that they assess their risk profile and seek opportunities to maintain and develop their skills with a flight instructor.”

Read the report: In-flight breakup involving Robinson R44 Raven I, VH-NBY, 3 km north of Broome Airport, Western Australia, on 4 July 2020

Publication Date
12/04/2023

Still not sure why you would have Popinjay being the front man for the media blurb? Shirley it would be much more appropriate for one of the conga line of Directors of Transport Safety; or even (God Forbid) the IIC?? Better still why not just rely on the primacy of the final report, after all PJ is just reading from the 'safety message'?? 

Quote:Safety message

The pilot’s operating handbook for this helicopter stated that the onset of unusual vibrations can indicate impending failure of a critical component. Pilots should land as soon as possible and formally declare the helicopter unserviceable. Crucially, the helicopter should not be returned to service until the source of the vibration, both on the ground and airborne, has been found and rectified.

The registered operator of an aircraft has ultimate responsibility for its airworthiness. This accident demonstrates the importance of following a conservative troubleshooting process that minimises risk. The tools to manage airworthiness are freely published by the Civil Aviation Safety Authority and include the correct use of an aircraft’s maintenance release to clearly communicate the state of the aircraft and any required maintenance action.

Finally, private pilots do not have the benefit of regular flying and frequent training and checking afforded to commercial pilots. Therefore it is recommended that private pilots do not rely on minimum training and checking and currency to keep them safe. Instead they are encouraged to assess their risk profile and seek opportunities to maintain and develop their skills with a flight instructor.

P2 comments: To begin this investigation to complete took 2 years, 9 months and 8 days. Although being 1 month past compliance with ICAO Annex 13 Para 7.3, there was a preliminary report published. Plus 6 days after the accident there was an update, which read very much like a interim/prelim report and was issued (I believe) because the investigation had already identified significant safety issues:  

Quote:Update: 10 July 2020

Wreckage information

Based on closed-circuit television (CCTV) footage and an examination of the wreckage, the ATSB investigation into the fatal R44 helicopter accident near Broome Airport on 4 July 2020 has determined that the helicopter experienced an in-flight breakup. The tail rotor gearbox assembly, tail rotor and empennage assembly separated soon after the helicopter lifted off. The fuselage then fell to the ground out of control.

The ATSB has conducted a detailed examination of the entire aircraft at Broome, and is transporting relevant components back to Canberra for more detailed examination. These components include the tail rotor gearbox, tail rotor, empennage, tail cone, tail rotor drive shaft, and flight controls. During this process, the ATSB has been consulting with the Robinson Helicopter Company (the helicopter manufacturer), the US National Transportation Safety Board and the Australian Civil Aviation Safety Authority.

Images of the components that separated are provided at the end of this update. The ATSB will not be releasing the CCTV footage due to its potentially distressing nature. The ATSB is providing access to the footage to relevant experts to assist with the investigation.

Additional information

The ATSB has interviewed a pilot who recently flew the helicopter and maintenance personnel who conducted maintenance on the helicopter. It has also obtained copies of the helicopter’s maintenance records and reviewed other documentation. Based on this information:

• The R44 Raven I helicopter involved in the accident (serial number 2544) was manufactured in 2018. It was imported new into Australia and was first registered on the Australian civil aircraft register in August 2018.
  
• The helicopter underwent its last periodic (100 hourly) inspection on 4 June 2020, with 286.9 hours total time in service.
  
• A pilot who flew the helicopter on 2 July 2020 to Broome Airport reported feeling unusual vibrations through the tail rotor pedals. He described it as if something was repetitively tapping through the pedals. The pilot of the accident flight also conducted a short flight in the helicopter and confirmed the unusual vibrations.
  
• Maintenance personnel conducted a dynamic tail rotor balance on 3 July 2020 (the day before the accident). The dynamic tail rotor balance was found to be within limits, and the maintenance personnel could not detect any unusual vibration on the ground.
  
• The accident flight was the first flight since the maintenance was conducted. Overall, the helicopter had 291 recorded hours in service.
  
• The Robinson R44 was certified in December 1992 and the R44 Raven I was introduced in January 2000. There are currently 558 R44s on the Australian civil aircraft register.
  

Further investigation

In the initial phase of its investigation, the ATSB is focussed on examining the wreckage, reviewing the CCTV footage and reviewing potentially related occurrences.

At this stage the reasons for the in-flight breakup are not known. The ATSB will provide further advice when relevant information is available.

Pilot advisory information

The R44 Pilot’s Operating Handbook (POH) includes the following 'safety tip':

Quote:A change in the sound or vibration of the helicopter may indicate an impending failure of a critical component. If unusual sound or vibration begins in flight, make a safe landing and have the aircraft thoroughly inspected before flight is resumed. Hover helicopter close to the ground to verify problem is resolved, and then have aircraft reinspected before resuming free flight.

The ATSB strongly endorses this advice, and urges any R44 pilot that experiences unusual vibrations through the tail rotor pedals to land as soon as possible and follow the advice in the POH safety tip.

 
So that's a Gold tick, IE the ATSB is actually doing their legislated job -    

After that the investigation timeline indicates that the ATSB also issued an interim report (as per ICAO Annex 13) only 5 weeks past the anniversary date of the accident.

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 04-14-2023

(04-13-2023, 09:36 AM)Peetwo Wrote:  Popinjay to the rescue: Broome R44 in flight breakup FR released? 

Mr Attribution still ATCB Media rep for this week? Via PJ HQ: 

Quote:ATSB releases Broome R44 helicopter accident investigation final report



Key points

• An overstress fracture, shortly after take-off, led to the separation of the tail rotor gearbox from the helicopter, and the subsequent separation of the aft tail section;
  
• Pilots had previously reported experiencing vibrations in the helicopter’s tail rotor pedals;
  
• Investigation highlights that aircraft should not be returned to service until known issues are rectified, and that a conservative approach to troubleshooting mechanical issues and return to service should be taken to minimise risk
  

An ATSB investigation into a fatal helicopter accident that occurred shortly after take-off from a yard in a Broome industrial suburb highlights the crucial importance of pilots formally declaring their helicopters to be unserviceable when the source of unusual vibrations has not been identified and rectified.

On 4 July 2020, a Robinson R44 helicopter with a pilot and three passengers on board conducted a vertical departure from an industrial property at Bilingurr, 3 km north of Broome Airport, to conduct a private joyflight. As the helicopter climbed clear of obstacles and transitioned to forward flight, witnesses on the ground heard a loud bang, and observed the helicopter’s empennage and tail rotor system separate and break away.

The helicopter continued to climb and commenced rotating to the right with increasing angular velocity, before control was lost, and it impacted a road on its right side. The pilot and the passenger, who were seated on the right side of the helicopter were fatally injured. The two passengers who were seated on the left side of the helicopter sustained serious injuries.

“The ATSB found that an overstress fracture of the tail rotor gearbox’s input cartridge occurred following a period of vibration in the helicopter’s tail rotor pedals,” said ATSB Chief Commissioner Angus Mitchell.

“This overstress fracture, shortly after take-off, led to the separation of the tail rotor gearbox from the helicopter, and the subsequent separation of the aft tail section.”

The ATSB’s investigation report notes the helicopter’s two previous flights were conducted by two separate pilots (including the accident pilot, who was also the helicopter’s owner), who both reported experiencing vibration in the helicopter’s tail rotor pedals.

In response the owner requested that their local approved maintenance organisation assess the vibration. Engineers from the maintenance organisation assessed the helicopter in the yard on the afternoon of 3 July. They found the tail rotor balance to be within limits, and a close inspection of the tail cone, tail rotor and empennage of the helicopter detected no issues. Further, no vibration in the pedals was detected during ground running of the helicopter in the yard.

Nonetheless, the maintenance engineer reported wanting a pilot to fly the helicopter to determine if the reported vibration in the pedals was detectable in flight.

However, while the requirement for a maintenance check flight was not recorded on the helicopter’s maintenance release, the owner of the maintenance organisation advised the ATSB that they advised both the owner and the pilot who first detected the vibrations of the requirement to fly the helicopter to provide more information. Friends and family of the owner of the helicopter stated that no request for further flight was made.

“As the vibration was reported to only occur in flight, and no defect was identified, it was reasonable to have concluded that the problem may still be present,” said Mr Mitchell.

“As such, the safest next step, which is recommended by the helicopter manufacturer, would be to conduct a graduated flight check of hovering then re-inspection. Preferably, this would be with only a prepared pilot on board.

“Instead, the next flight, during which the accident occurred, involved the conduct of a high‑power towering take-off from a confined area with 3 passengers on board.”

The investigation report notes that the registered operator of an aircraft has ultimate responsibility for its airworthiness.

“This accident demonstrates the importance of following a conservative troubleshooting process that minimises risk.”

Mr Mitchell noted that while the source of the loading that led to the overstress fracture was not conclusively determined, the pilot’s operating handbook for the R44 helicopter states that the onset of unusual vibrations can indicate impending failure of a critical component.

“The pilot’s handbook states that pilots should land as soon as possible and formally declare the helicopter unserviceable.

“Crucially, the helicopter should not be returned to service until the source of the vibration, both on the ground and airborne, has been found and rectified.”

Mr Michell also noted that private pilots do not, unlike commercial and airline pilots, have the benefit of regular flying and frequent training and checking.

“The ATSB recommends private pilots to not rely on the minimum training and checking and training currency requirements to keep safe, and that they assess their risk profile and seek opportunities to maintain and develop their skills with a flight instructor.”

Read the report: In-flight breakup involving Robinson R44 Raven I, VH-NBY, 3 km north of Broome Airport, Western Australia, on 4 July 2020

Publication Date
12/04/2023

Still not sure why you would have Popinjay being the front man for the media blurb? Shirley it would be much more appropriate for one of the conga line of Directors of Transport Safety; or even (God Forbid) the IIC?? Better still why not just rely on the primacy of the final report, after all PJ is just reading from the 'safety message'?? 

Quote:Safety message

The pilot’s operating handbook for this helicopter stated that the onset of unusual vibrations can indicate impending failure of a critical component. Pilots should land as soon as possible and formally declare the helicopter unserviceable. Crucially, the helicopter should not be returned to service until the source of the vibration, both on the ground and airborne, has been found and rectified.

The registered operator of an aircraft has ultimate responsibility for its airworthiness. This accident demonstrates the importance of following a conservative troubleshooting process that minimises risk. The tools to manage airworthiness are freely published by the Civil Aviation Safety Authority and include the correct use of an aircraft’s maintenance release to clearly communicate the state of the aircraft and any required maintenance action.

Finally, private pilots do not have the benefit of regular flying and frequent training and checking afforded to commercial pilots. Therefore it is recommended that private pilots do not rely on minimum training and checking and currency to keep them safe. Instead they are encouraged to assess their risk profile and seek opportunities to maintain and develop their skills with a flight instructor.

P2 comments: To begin this investigation to complete took 2 years, 9 months and 8 days. Although being 1 month past compliance with ICAO Annex 13 Para 7.3, there was a preliminary report published. Plus 6 days after the accident there was an update, which read very much like a interim/prelim report and was issued (I believe) because the investigation had already identified significant safety issues:  

Quote:Update: 10 July 2020

Wreckage information

Based on closed-circuit television (CCTV) footage and an examination of the wreckage, the ATSB investigation into the fatal R44 helicopter accident near Broome Airport on 4 July 2020 has determined that the helicopter experienced an in-flight breakup. The tail rotor gearbox assembly, tail rotor and empennage assembly separated soon after the helicopter lifted off. The fuselage then fell to the ground out of control.

The ATSB has conducted a detailed examination of the entire aircraft at Broome, and is transporting relevant components back to Canberra for more detailed examination. These components include the tail rotor gearbox, tail rotor, empennage, tail cone, tail rotor drive shaft, and flight controls. During this process, the ATSB has been consulting with the Robinson Helicopter Company (the helicopter manufacturer), the US National Transportation Safety Board and the Australian Civil Aviation Safety Authority.

Images of the components that separated are provided at the end of this update. The ATSB will not be releasing the CCTV footage due to its potentially distressing nature. The ATSB is providing access to the footage to relevant experts to assist with the investigation.

Additional information

The ATSB has interviewed a pilot who recently flew the helicopter and maintenance personnel who conducted maintenance on the helicopter. It has also obtained copies of the helicopter’s maintenance records and reviewed other documentation. Based on this information:

• The R44 Raven I helicopter involved in the accident (serial number 2544) was manufactured in 2018. It was imported new into Australia and was first registered on the Australian civil aircraft register in August 2018.
  
• The helicopter underwent its last periodic (100 hourly) inspection on 4 June 2020, with 286.9 hours total time in service.
  
• A pilot who flew the helicopter on 2 July 2020 to Broome Airport reported feeling unusual vibrations through the tail rotor pedals. He described it as if something was repetitively tapping through the pedals. The pilot of the accident flight also conducted a short flight in the helicopter and confirmed the unusual vibrations.
  
• Maintenance personnel conducted a dynamic tail rotor balance on 3 July 2020 (the day before the accident). The dynamic tail rotor balance was found to be within limits, and the maintenance personnel could not detect any unusual vibration on the ground.
  
• The accident flight was the first flight since the maintenance was conducted. Overall, the helicopter had 291 recorded hours in service.
  
• The Robinson R44 was certified in December 1992 and the R44 Raven I was introduced in January 2000. There are currently 558 R44s on the Australian civil aircraft register.
  

Further investigation

In the initial phase of its investigation, the ATSB is focussed on examining the wreckage, reviewing the CCTV footage and reviewing potentially related occurrences.

At this stage the reasons for the in-flight breakup are not known. The ATSB will provide further advice when relevant information is available.

Pilot advisory information

The R44 Pilot’s Operating Handbook (POH) includes the following 'safety tip':

Quote:A change in the sound or vibration of the helicopter may indicate an impending failure of a critical component. If unusual sound or vibration begins in flight, make a safe landing and have the aircraft thoroughly inspected before flight is resumed. Hover helicopter close to the ground to verify problem is resolved, and then have aircraft reinspected before resuming free flight.

The ATSB strongly endorses this advice, and urges any R44 pilot that experiences unusual vibrations through the tail rotor pedals to land as soon as possible and follow the advice in the POH safety tip.

 
So that's a Gold tick, IE the ATSB is actually doing their legislated job -    

After that the investigation timeline indicates that the ATSB also issued an interim report (as per ICAO Annex 13) only 5 weeks past the anniversary date of the accident.

Addendum: 

Via Oz Aviation:

Quote:R44 HELICOPTER CRASH THAT KILLED 12-YEAR-OLD GIRL WAS PREVENTABLE

written by Jake Nelson | April 12, 2023



The family of a 12-year-old girl killed in a July 2020 helicopter crash in Broome has called for better regulation after an ATSB investigation concluded the accident could have been prevented by removing the aircraft from service following pilot reports of unusual vibrations.

The Robinson R44 helicopter, VH-NBY (pictured), had just taken off for a private joy flight when its empennage and tail rotor system separated and broke away, causing it to crash into a road. The pilot, along with 12-year-old passenger Amber Jess Millar (inset), were killed in the accident, with two other passengers seriously injured.

According to the ATSB’s report, the crash was caused by an overstress fracture in the tail rotor gearbox’s input cartridge that may have been picked up had more been done about reports of unusual vibrations in the rotor pedals.

“As the vibration was reported to only occur in flight, and no defect was identified, it was reasonable to have concluded that the problem may still be present,” said the ATSB’s chief commissioner Angus Mitchell.

“As such, the safest next step, which is recommended by the helicopter manufacturer, would be to conduct a graduated flight check of hovering then re-inspection. Preferably, this would be with only a prepared pilot on board. Instead, the next flight, during which the accident occurred, involved the conduct of a high‑power towering take-off from a confined area with 3 passengers on board.

“This investigation highlights that helicopters should not be returned to service until the source of any unusual vibration in vital components such as rotor pedals have been found and rectified,” he said.

In a statement, Amber’s mother and stepfather, Clint and Fiona Benbow, have excoriated the operator of the joy flight for not taking the aircraft out of service, and criticised the length of the ATSB investigation.

“Amber’s death was preventable – as highlighted by the Australian Transport Safety Bureau (ATSB) report, which demonstrates the flight should never have taken place. Amber would be here now if the tourism operator and their maintenance team were working to, and held accountable to, higher standards,” they said.

“While we thank the ATSB for its thorough investigation, we are incredibly frustrated that it has taken 2 years and 9 months. This may have a significant knock-on effect in holding people to account for Amber’s death, as WorkSafe must commence a prosecution within 3 years of an accident under the then applicable Occupational Safety and Health Act 1984.

“We ask Minister Bill Johnston to instruct WorkSafe to swiftly examine these new facts and determine if there can be prosecutions within the 3-year timeframe under the Act. With their responsibilities for the safety of locals and visitors, we hope that the relevant Ministers will be sympathetic to our calls for action on Amber’s death.”

MTF...P2 

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