Closing the safety loop - Coroners, ATSB & CASA - Printable Version

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 02-22-2016

As time goes by.

The tragic Canley Vale accident fades slowly from the public memory, the highly criticised ATSB report gathers dust and hope of the mooted Senate inquiry into the event becomes a faint, distant memory as the endless wait for the Coroners inquest stretches from far away to infinity. 

There has been one inquest; that into the death of flight nurse Kathy Sheppard, which for the coroner at least was ‘straight forward’.  But the delayed inquest into the death of Andy Wilson does not seem to appear on radar.  The wait must be living hell for the family, the Feb 15 article by Rory Callinan (courtesy SMH) reveals some of a fathers frustration and anger; it has also caused anxiety and concern to those who are still waiting to be called as witness.

PAIN has received several letters from people genuinely concerned, folks without a dog in the fight; just sympathy for the family and a desire to ensure that everything that can be done, is done, properly, openly and honestly in a timely manner.

Quote:I write in regard to the Canley Vale plane crash of 2010.  I had been waiting for quite some time to be called as a witness to the Coronial inquest into the deaths of Andrew Wilson and Kathy Sheppard.  I had been advised that I would be contacted to present my version of events as to what I saw that day.  I have never been contacted and now I read that the Coronial Inquest was held in August 2015 and it's all over.

I've just Googled the plane crash and came across your comments in regard to "nobody who made statements to the ATSB being called as witnesses."  I can confirm that I supplied a statement to an ATSB investigator and spoke to him on either 2 or 3 occasions in total.  I also supplied a statement to the Police and they informed me that at a time closer to the Coronial Inquest they would be back in touch with me as they wished to take a video of the flight path to present as part of the Inquest and that I would be called as a witness.  That was the last I have ever heard from anyone on the subject.  I have not been called as a witness for anything.

At the time of giving my statement to ATSB I was questioned as to whether I had plane knowledge or worked within the industry.  I don't but I do work with spare parts and engines in the earthmoving industry.  He advised me that my use of terminology was pretty good for someone who didn't work with planes.  I'm not blowing my own trumpet, just indicating that he understood what I was telling him and that he was happy with how I had described things.

This plane first developed engine trouble directly over the top of me.  I know what I saw and what I heard while I stood there and watched and it's haunted me ever since.  I have the RAAF conduct pilot training over my property on a regular basis and I hear and see what they do when they shut plane engines down and re-start them.  I hear all the little noises that they make just before the engine re-starts, all the ticks and the hums, I hear the increase in the engines etc.

I could clearly hear a fuel problem that day.  With the echo of the valley, it sounded like someone sitting in front of me revving a V8 car, surging fuel over and over again.  Whether it was the fuel or a fuel related spare part, we won't know due to the lack of evidence left after the fire.  I could hear what sounded like a crunching noise, rather like metal crackling through the system like something you would expect to hear if you had metal filings if something had let go.  While I understand at the end of the day, it's the point of impact that they are investigating and it's easy to point the finger at the pilot and say he handled the emergency incorrectly, if it was me I'd be pointing at what caused the emergency in the first place.

Now that I will never be called as a witness I guess I needed to get it off my chest.  I really feel for the families because I don't think they got the correct outcome and answers.  From where I was standing, I thought Andrew handled it pretty well.  If he'd landed it at the RAAF base they'd still be here today but I gather that financial aspects of the transport industry indicate that he may have been under pressure to return to Bankstown.  The conspiracy theorist in me says the investigation and result was a cover up.

I can still see the time on the clock in the minute leading up to all this, I can still hear the change in the engine as it went over the top of me, the panic as I thought it was going to come down in front of me and trying to work out how to deal with a plane crash and two young children at the same time, I see the path the plane took as it turned around, the overwhelming noise that engine was making yet the other engine was apparently fine.  Then the noise stopped, the engine sounded fine and I thought everything would be OK.  It really upset me to hear that they didn't make it back.

Anyway, that's my version.....

CASA and the ATSB have much to be gained from the delay; the management of the investigation and the report provided leave much to be desired.  Many thought Pel-Air was a disgrace; I say that Canley Vale overshadows that disgusting event.  Much will depend on how the game is played in the coronial inquest, which evidence is allowed, which evidence is able to withstand testing etc.  But at the end of the day, it will that which the coroner is able to understand and assess that will win the day.  Lets hope this inquest is soon and a Senate inquiry follows rapidly afterwards.  

Pel Air was not the first aberration, lets hope that Canley Vale will be the last.  

Selah.

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RE: Closing the safety loop - Coroners, ATSB & CASA - P7_TOM - 02-22-2016

Strange thing is; the same manager was in charge of both Canley Vale and Pel Air investigations; both have serious question marks over the CASA involvement and ATSB ‘reporting’.

Even stranger is the latest rumour that the same person is reported as saying publicly the Rev. Forsyth was either bullied, brainwashed, seduced or coerced into writing a defamatory, scurrilous, untruthful report and providing it to the minister; even thinks the good Rev. should be prosecuted. All unfounded rumour of course, but even so, it's all passing strange, don’t you think?

But, I do know who I’d believe, if push ever came to shove.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Ziggy - 02-24-2016

(02-22-2016, 05:27 AM)kharon Wrote:  As time goes by.

The tragic Canley Vale accident fades slowly from the public memory, the highly criticised ATSB report gathers dust and hope of the mooted Senate inquiry into the event becomes a faint, distant memory as the endless wait for the Coroners inquest stretches from far away to infinity. 

There has been one inquest; that into the death of flight nurse Kathy Sheppard, which for the coroner at least was ‘straight forward’.  But the delayed inquest into the death of Andy Wilson does not seem to appear on radar.  The wait must be living hell for the family, the Feb 15 article by Rory Callinan (courtesy SMH) reveals some of a fathers frustration and anger; it has also caused anxiety and concern to those who are still waiting to be called as witness.

PAIN has received several letters from people genuinely concerned, folks without a dog in the fight; just sympathy for the family and a desire to ensure that everything that can be done, is done, properly, openly and honestly in a timely manner.

Quote:I write in regard to the Canley Vale plane crash of 2010.  I had been waiting for quite some time to be called as a witness to the Coronial inquest into the deaths of Andrew Wilson and Kathy Sheppard.  I had been advised that I would be contacted to present my version of events as to what I saw that day.  I have never been contacted and now I read that the Coronial Inquest was held in August 2015 and it's all over.

I've just Googled the plane crash and came across your comments in regard to "nobody who made statements to the ATSB being called as witnesses."  I can confirm that I supplied a statement to an ATSB investigator and spoke to him on either 2 or 3 occasions in total.  I also supplied a statement to the Police and they informed me that at a time closer to the Coronial Inquest they would be back in touch with me as they wished to take a video of the flight path to present as part of the Inquest and that I would be called as a witness.  That was the last I have ever heard from anyone on the subject.  I have not been called as a witness for anything.

At the time of giving my statement to ATSB I was questioned as to whether I had plane knowledge or worked within the industry.  I don't but I do work with spare parts and engines in the earthmoving industry.  He advised me that my use of terminology was pretty good for someone who didn't work with planes.  I'm not blowing my own trumpet, just indicating that he understood what I was telling him and that he was happy with how I had described things.

This plane first developed engine trouble directly over the top of me.  I know what I saw and what I heard while I stood there and watched and it's haunted me ever since.  I have the RAAF conduct pilot training over my property on a regular basis and I hear and see what they do when they shut plane engines down and re-start them.  I hear all the little noises that they make just before the engine re-starts, all the ticks and the hums, I hear the increase in the engines etc.

I could clearly hear a fuel problem that day.  With the echo of the valley, it sounded like someone sitting in front of me revving a V8 car, surging fuel over and over again.  Whether it was the fuel or a fuel related spare part, we won't know due to the lack of evidence left after the fire.  I could hear what sounded like a crunching noise, rather like metal crackling through the system like something you would expect to hear if you had metal filings if something had let go.  While I understand at the end of the day, it's the point of impact that they are investigating and it's easy to point the finger at the pilot and say he handled the emergency incorrectly, if it was me I'd be pointing at what caused the emergency in the first place.

Now that I will never be called as a witness I guess I needed to get it off my chest.  I really feel for the families because I don't think they got the correct outcome and answers.  From where I was standing, I thought Andrew handled it pretty well.  If he'd landed it at the RAAF base they'd still be here today but I gather that financial aspects of the transport industry indicate that he may have been under pressure to return to Bankstown.  The conspiracy theorist in me says the investigation and result was a cover up.

I can still see the time on the clock in the minute leading up to all this, I can still hear the change in the engine as it went over the top of me, the panic as I thought it was going to come down in front of me and trying to work out how to deal with a plane crash and two young children at the same time, I see the path the plane took as it turned around, the overwhelming noise that engine was making yet the other engine was apparently fine.  Then the noise stopped, the engine sounded fine and I thought everything would be OK.  It really upset me to hear that they didn't make it back.

Anyway, that's my version.....

CASA and the ATSB have much to be gained from the delay; the management of the investigation and the report provided leave much to be desired.  Many thought Pel-Air was a disgrace; I say that Canley Vale overshadows that disgusting event.  Much will depend on how the game is played in the coronial inquest, which evidence is allowed, which evidence is able to withstand testing etc.  But at the end of the day, it will that which the coroner is able to understand and assess that will win the day.  Lets hope this inquest is soon and a Senate inquiry follows rapidly afterwards.  

Pel Air was not the first aberration, lets hope that Canley Vale will be the last.  

Selah.

CASA-BLINKERS...remain ON, as time goes by.

A Collective System/Porfolioitis Problem for Australian Aviation.

The Parallels regarding the investigation of both the ongoing Pel-Air investigation and The Tragic Canley Vale Crash Investigation.

Even as a DIP, my rights and the limitations are put in place by the Almighty Fort and their Alliances. The  Aviation Alphabet Atrocity. All entwined together.

As a Opinion only regarding what one would deem important "Evidence" not collected and used. It's not just that only people who voice factual concerns are ignored, in some cases, intimidation and harassment have been reported.

This is clearly not safe practice.

For the new Minister of Infrastructure.

First thing: Apologise. Get them all to Apologise.
Yet that will not happen due to, was seems as Accountability being omitted from the Parliamentary Dictionary. 
Apologise for all the uncalled, dragged out with no outcome Politics Games regarding the Pel-Air ditching and each Aviation Incident you know has been hindered by Possible (well, quite well known, Chambers report, Dirty Word now isn't it?)...Trespassing in the course of Investigations of other footprints and handshakes. 

Second: Gravity places Aviation in a Different Category from Roads etc.
A specialised team of Real Experts need to collapse the Wall around the Fort and simplify the fuck out of it so it's SAFE! 

Wake Up and smell the Potential Flying Danger of a Serious Accident!
Oh that has already happened and as we speak being swept under green carpet.
Safe as slippery tiles Minister.

Why the very detailed, accurate statement above was not taken into account is to me quite negligent. Not surprising, just negligent. Especially considering the History of the Organisation from other sound Statements.

It is like a Boom-Crash-History repeat of other Serious Aviation Accidents that has clear information right in front of their eyes and ears. Learning applied. No.
Astonishing, to say the least.

The hard-working Australian Citizens on board the struggling aircraft. The brave Pilot Andy, that avoided a School, avoiding further carnage of incinerated bodies The brave Nurse, Kathy, a mother doing her job till the end. May you both be at peace.
I will unite with your beloved living, along with others to request a RC into Aviation Safety and Fairness.

I believe it is time. No more Tick-Tock. 
Now into the 25th Hour.
Did I already say Dangerous Practice??

Yet names of the people seem to glide by and fact still are flying under the Political Radar, as I perceive.

Crawling into Seven years, Alive and watching is nothing short of Pitiful.
What I have witnesses, others who are aware too, is the slither of detail given to the public that "all is well". Safe skies. Great Investigative Body. 
Piffle!

Not wanting to be an instigator of trouble or cause a kerfuffle...
But wouldn't one think that not only does the Canley Vale Crash deserve a Senate Inquiry to say the least?

Sure seems like time for a mass writing to the AG for a RC??

Think about it.


Perverting the Course of Justice is a Common Law Matter, carrying possible imprisonment. *Fabricating or disposing of Evidence.* (From Act 3.)
Enough is Enough. Really.

It's just plane/ plain Dangerous chair swapping of Individuals whiteout a clue.


I think I will remind the Pollies of the prayer they say each morning, acknowledgement of our Country and the "advancement of...the Welfare of the People of Australia."

Really.
Could the Investigators, MP, DP and all the rest, please look Me and any other Person who are still suffering, in the eyes and without bumbling, explain the squeeze felt from the Hands of Ignorant Fists.

Shuffling off...

Ziggy

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 02-27-2016

A quiet, valuable achievement.

K Sheppard   A Wilson.    At the Coroners inquest.

I don’t expect a head of steam would achieve very much; fury after the fact is  of little value.  But I am curious about the selection of witnesses to appear in this below the radar coroner’s inquiry.  I am also curious that the only published article we could find was a very crafty piece published in the AAP loop which reads as though young Wilson ‘killed’ Sheppard and that the inquest was all about one death, not two.  Considering the amount of press Hempel and others got, you could reasonably expect a little more coverage.  The only reason I can fathom is that very few people even knew the inquest was on.  Certainly several who had been advised that they were to be witness did not.  Gutted, gobsmacked and angry are some of the comments.  

No doubt it was all done legal and nice, the coroner really only to do his job and determine the cause of death, not too many facts needed for that – two killed in a crash: full stop.  CASA lift up the carpet, ATSB sweep the mess underneath; everyone off to lunch.  Nothing to see move along.

There was even a trite, mealy mouthed recommendation from the coroner:-

Quote:2. That CASA undertake public consultations in order to assist CASA in the development of a legislative proposal enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that; a. a significant safety risk exists or existed in an aviation operation; and

b. evidence of a witness or witnesses likely to have knowledge of an aviation safety risk cannot be obtained in any other way.

Read that half a dozen times, carefully

Quote:"enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that; a. a significant safety risk exists or existed in an aviation operation; etc."

Pure fiction. Had we been invited or even informed of the scheduled date, I and others would have very much liked to be there, if only just to listen to the ATSB/CASA discourse which prompted such a recommendation; I really would.  Must have been a work of art and with no dissention offered, a very easy piece to sell.  

Quote:“to compel the attendance of persons at compulsory sworn interviews”

Does this imply that people did not turn up for interview; or, perhaps many witnesses were not summoned to interview; or, CASA did not bother to interview anyone?   Many had ATSB interviews, several provided empirical evidence, we can’t find any one witness (yet) who was informed of the inquest, let alone attended.

As I say, all neat and tidy, dry as dust and no skin off the watchdog’s arse.  If you thought the handling of Pel-Air was a clever bit of legerdemain, Canley Vale will blow your socks off: the ATSB report is a good place to start.  ATSB may well have written the ‘technical’ analysis, for what that’s worth, but the back end was pure malice aforethought and had little to do with the accident; just the politics of yet another predetermined result.

As the members of the Senate standing committee have been advised on several occasions; you think Pel-Air was a rum do? Brothers, you ain’t seen nothing yet.  Just take a peep under that plush, expensive carpet, then tell me what you see.  We cannot stop this from happening, perhaps you can.  But after the nett result on Pel-Air, we wonder.

It is a tale Told by an idiot, full of sound and fury, Signifying nothing.

This ain’t good enough, not by a bloody long shot.

Selah.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Gobbledock - 03-14-2016

Loop? What loop?

Kharon, Canley Vale is an abboration. I have had numerous discussions with well placed people and I can confirm that it puts the Pel Air shennanigans to shame so to speak. Two beautiful people lost their lives and it should never have occurred. CAsA's s actions and the subsequent ATSB investigation has only produced paperwork fit for wiping one's ass with.

If ever a royal commission into CAsA and the ATsB was to be actioned then Canley Vale is the icing on top of the Pel Air cake, and that comes on top of the not to be forgotten Lockhart crash, a bureaucratic example of government malfeasance at the highest level.

The alphabet soup agencies might prattle on about closing the safety loop, which of course is a necessary part of root cause methodology, but that of course is an expectation placed upon industry, upon us the IOS, not upon themselves. Those agencies leave open loops so large that you could fly an A380 through it.

Dear Senators,

Plenty of work in the pipeline for you if you are interested, what with the above mentioned accident, CAsA's ongoing buggerisation of industry, the ATsB's woeful and collaborated investigation reports, the MH370 folly, and ASA's ongoing legacy of mates rates, snouts in the trough ,corporate fiddling and problematic airspace issues, and Murky Mandarins and dodgy airport dealings, I think you have decades of work ahead of you!

TICK TOCK

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-28-2016

Easter Mundy ramble - PelAir & more lessons missed.

In the 1st PelAir cover-up investigation (not totally sure about the 2nd just yet ), another one of the totally glossed over links in the causal chain was in areas such as Operational Control/Support or lack there of. 

Operational Control should include but is not limited to aspects like; monitoring flight progress, checking & booking en-route fuel/provisions/approvals/etc. requirements, providing up to date operational information (including latest WX & NOTAMS), predictive and/or monitoring of crew fatigue issues (FRMS). 

In the PelAir example the obvious lack of operational support & the pilot acceptance of this lack of support should or would, in a normal AAI setting, be defined as a 'normalised deficiency' or 'deviation'.  According to the following excellent US SAFE Pilots blog a 'ND' is symptomatic of the human ability to adapt to very trying & sometimes bizarre circumstances..

Quote:The Dark Side of Adaptation; “Normalizing!”


Adaptability is an important defining trait of human existence and probably most responsible for our survival and growth as a species. Humans live happily in every corner of our planet from polar wastelands to equatorial rain forests and in every case seem to adapt and flourish. I am sure you have seen pictures, or experienced first hand, some amazing conditions people become comfortable with and contentedly call “home.” At first it might be awkward and weird but pretty soon it becomes “normal” as we adapt!


Adaptability is also an important trait for pilots. We must overcome diverse challenges transitioning to new equipment or flying in challenging environments. These new conditions at first require courage and ingenuity, but ultimately we conform and become comfortable. Air Inuit in northern Canada has an Op. Spec. to fly passengers “VFR” in Twin Otters with only 300′ ceiling and one mile viz (though this requires <90K, flaps 10 degrees and synthetic vision system for safety).


  
There is, however, a dark side to adaptability and that is the “normalization of deviance.” This term was coined by Diane Vaughan, a professor at Columbia University investigating NASA’s Challenger launch decision in 1986. The process of “normalization of deviance” is when a person or organization becomes so familiar with an odd or deviant behavior that it no longer seems strange and alarming but becomes accepted as the “new normal.” This chameleon psychic process seems to be an integral part of our human survival mechanism. Given time we seem to adapt and accept just about any deviant structure and made it a comfortable part of our world. This is also why a objective “standard operating procedure” (and the discipline to follow it) is such an essential tool in aviation safety.

In the 1980s, NASA’s Space Shuttles were being launched on increasingly short intervals. And despite the solid booster “O” rings leaking at launch temperatures much lower than specified, time pressures, historic success (the absence of immediate bad outcomes) and “group think” led to acceptance of these increasingly unsafe conditions. This “normalization of deviance” ultimately resulted in a dramatically public national tragedy.

The fact that a similar NASA accident occurred only 8 years later with the “normal shedding of fuel tank insulation” on launch shows how pernicious this problem can be. (The only benefit gained from these tragedies is that recent work by NASA on accident theory is amazing.)


“So that was NASA but how does this effect us in our everyday flying?” Please look around your airport carefully. I am sure you have been witness to a pilot who has strangely unsafe practices that they personally regard as “normal?” Over time these “rogue pilots” have unfortunately drifted far from objectively accepted safety practices and personally “normalized” techniques that are clearly unsafe. Maybe they have just become “less than proficient” but this too has become “acceptable” or “justified” due to high cost or time constraints. We pilots are a pretty respectful and tolerant bunch so often this “accident waiting to happen” continues unchallenged until the inevitable occurs. Let’s change this please and take action *before* the accident. “Friends don’t let friends fly unsafe!”

Please check out safety writer Dr. Bill Rhodes definition of “scary pilots” in an article by John King. Tony Kern also documents this phenomenon in the military with his book Rogue Pilot. And popular blogger Tom Rapp explains a scary 135 charter example in detail with his examination of normalization in the Bedford Gulfstream accident.

This dangerous “normalization of deviance” occurs even more easily in private aviation where the only normative filter is a (often perfunctory) 2 year flight review. Please don’t stand by if you are aware of cases of compliance drift and normalization. Embrace your normalizing friend and talk some sense into them, carefully and honestly. Let’s embrace the same culture change that cured a lot of unsafe drunk driving; “Friends don’t let friends fly unsafe!” It would be much better to have this friend mad at you than injured. Let’s modify our culture and help everyone embrace a higher standard of safety in their flying. And please Join SAFE in our mission of pursuing aviation excellence. The amazing member benefits alone make this commitment painless and fun. See you at the airport.


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Author: David St. George
Master CFI, 141Chief Instructor, FAA DPE, ATP (ME/SE) View all posts by David St. George

P2: The House of RAPP link provided - normalization in the Bedford Gulfstream accident - was referenced in an AA International thread post, see here:

(02-10-2016, 02:03 PM)Peetwo Wrote:  Normalised deviation and intentional, habitual non-compliance - A most disturbing tale, very well reviewed & condemned by two professional pilots.     
..Next from Ron Rapp, courtesy the House of Rapp  :

Quote:Bedford and the Normalization of Deviance

by Ron Rapp on December 20, 2015 in Opinion Leaders • 139 Comments

Like many pilots, I read accident reports all the time. This may seem morbid to people outside “the biz”, but those of us on the inside know that learning what went wrong is an important step in avoiding the fate suffered by those aviators. And after fifteen years in the flying business, the NTSB’s recently-released report on the 2014 Gulfstream IV crash in Bedford, Massachusetts is one of the most disturbing I’ve ever laid eyes on.

If you’re not familiar with the accident, it’s quite simple to explain: the highly experienced crew of a Gulfstream IV-SP attempted to takeoff with the gust lock (often referred to as a “control lock”) engaged. The aircraft exited the end of the runway and broke apart when it encountered a steep culvert. The ensuing fire killed all aboard.

Sounds pretty open-and shut, doesn’t it? There have been dozens of accidents caused by the flight crew’s failure to remove the gust/control lock prior to flight. Professional test pilots have done it on multiple occasions, ranging from the prototype B-17 bomber in 1935 to the DHC-4 Caribou in 1992. But in this case, the NTSB report details a long series of actions and habitual behaviors which are so far beyond the pale that they defy the standard description of “pilot error”.

Just the Facts

Let me summarize the ten most pertinent errors and omissions of this incident for you:

1. There are five checklists which must be run prior to flying. The pilots ran none of them. CVR data and pilot interviews revealed that checklists simply were not used. This was not an anomaly, it was standard operating procedure for them.
   
2. Obviously the gust lock was not removed prior to flying. This is a very big, very visible, bright red handle which sticks up vertically right between the throttles and the flap handle. As the Simon & Chabris selective attention test demonstrates, it’s not necessarily hard to miss the gust lock handle protruding six inches above the rest of the center pedestal. But it’s also the precise reason we have checklists and procedures in the first place.
   
3. Flight control checks were not performed on this flight, nor were they ever performed. Hundreds of flights worth of data from the FDR and pilot interviews confirm it.
   
4. The crew received a Rudder Limit message indicating that the rudder’s load limiter had activated. This is abnormal. The crew saw the alert. We know this because it was verbalized. Action taken? None.
   
5. The Pilot Flying (PF) was unable to push the power levers far enough forward to achieve takeoff thrust. Worse, he actually verbalized that he wasn’t able to get full power, yet continued the takeoff anyway.
   
6. The Pilot Not Flying (PNF) was supposed to monitor the engines and verbally call out when takeoff power was set. He failed to perform this task.
   
7. Aerodynamics naturally move the elevator up (and therefore the control column aft) as the airplane accelerates. Gulfstream pilots are trained to look for this. It didn’t happen, and it wasn’t caught by either pilot.
   
8. The Pilot Flying realized the gust lock was engaged, and said so verbally several times. At this point, the aircraft was traveling 128 knots had used 3,100 feet of runway; about 5,000 feet remained. In other words, they had plenty of time to abort the takeoff. They chose to continue anyway.
   
9. One of the pilots pulled the flight power shutoff handle to remove hydraulic pressure from the flight controls in an attempt to release the gust lock while accelerating down the runway. The FPSOV was not designed for this purpose, and you won’t find any G-IV manual advocating this procedure.  Because it doesn’t work.
   
10. By the time they realized it wouldn’t work and began the abort attempt, it was too late. The aircraft was traveling at 162 knots (186 mph!) and only about 2,700 feet of pavement remained. The hydraulically-actuated ground spoilers — which greatly aid in stopping the aircraft by placing most of its weight back on the wheels to increase rolling resistance and braking efficiency — were no longer available because the crew had removed hydraulic power to the flight controls.
    
    

Gulfstream IV gust lock (the red handle, shown here in the engaged position)

Industry Responses

Gulfstream has been sued by the victim’s families. Attorneys claim that the gust lock was defective, and that this is the primary reason for the crash. False. The gust lock is designed to prevent damage to the flight controls from wind gusts. It does that job admirably. It also prevents application of full takeoff power, but the fact that the pilot was able to physically push the power levers so far forward simply illustrates that anything can be broken if you put enough muscle into it.

The throttle portion of the gust lock may have failed to meet a technical certification requirement, but it was not the cause of the accident.  The responsibility for ensuring the gust lock is disengaged prior to takeoff lies with the pilots, not the manufacturer of the airplane.

Gulfstream pilot and Code7700 author James Albright calls the crash involuntary manslaughter. I agree. This wasn’t a normal accident chain. The pilots knew what was wrong while there was still plenty of time to stop it. They had all the facts you and I have today. They chose to continue anyway. It’s the most inexplicable thing I’ve yet seen a professional pilot do, and I’ve seen a lot of crazy things. If locked flight controls don’t prompt a takeoff abort, nothing will.

Albright’s analysis is outstanding: direct and factual. I predict there will be no shortage of articles and opinions on this accident. It will be pointed to and discussed for years as a bright, shining example of how not to operate an aircraft.

In response to the crash, former NTSB member John Goglia has called for video cameras in the cockpit, with footage to be regularly reviewed to ensure pilots are completing checklists.  Despite the good intentions, this proposal would not achieve the desired end. 

Pilots are already work in the presence of cockpit voice recorders, flight data recorders, ATC communication recording, radar data recording, and more.  If a pilot needs to be videotaped too, I’d respectfully suggest that this person should be relieved of duty.  No, the problem here is not going to be solved by hauling Big Brother further into the cockpit.

A better model would be that of the FOQA program, where information from flight data recorders is downloaded and analyzed periodically in a no-hazard environment.  The pilots, the company, and the FAA each get something valuable.  It’s less stick, more carrot.  I would also add that this sort of program is in keeping with the Fed’s recent emphasis on compliance over enforcement action.

The Normalization of Deviance

What I, and probably you, are most interested in is determining how well-respected, experienced, and accomplished pilots who’ve been through the best training the industry has to offer reached the point where their performance is so bad that a CFI wouldn’t accept it from a primary student on their very first flight.

After reading through the litany of errors and malfeasance present in this accident report, it’s tempting to brush the whole thing off and say “this could never happen to me”.  I sincerely believe doing so would be a grave mistake. It absolutely can happen to any of us, just as it has to plenty of well-trained, experienced, intelligent pilots. Test pilots. People who are much better than you or I will ever be.

But how? Clearly the Bedford pilots were capable of following proper procedures, and did so at carefully selected times: at recurrent training events, during IS-BAO audits, on checkrides, and various other occasions.

Goglia, Albright, the NTSB, and others are focusing on “complacency” as a root cause, but I believe there might be a more detailed explanation.  The true accident chain on this crash formed over a long, long period of time — decades, most likely — through a process known as the normalization of deviance.

Quote:Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety. People grow more accustomed to the deviant behavior the more it occurs. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

This concept was developed by sociologist and Columbia University professor Diane Vaughan after the Challenger explosion. NASA fell victim to it in 1986, and then got hit again when the Columbia disaster occurred in 2003. If they couldn’t escape its clutches, you might wonder what hope we have. Well, for one thing, spaceflight in general and the shuttle program in particular are  specialized, experimental types of flying.  They demand acceptance of a far higher risk profile than corporate, charter, and private aviation.

I believe the first step in avoiding “normalization of deviance” is awareness, just as admitting you have a problem is the first step in recovery from substance addiction.  After all, if you can’t detect the presence of a problem, how can you possibly fix it?

There are several factors which tend to sprout normalization of deviance:

• First and foremost is the attitude that rules are stupid and/or inefficient. Pilots, who tend to be independent Type A personalities anyway, often develop shortcuts or workarounds when the checklist, regulation, training, or professional standard seems inefficient. Example: the boss in on board and we can’t sit here for several minutes running checklists; I did a cockpit flow, so let’s just get going!
  
• Sometimes pilots learn a deviation without realizing it. Formalized training only covers part of what an aviator needs to know to fly in the real world. The rest comes from senior pilots, training captains, and tribal knowledge. What’s taught is not always correct.
  
• Often, the internal justification for cognizant rule breaking includes the “good” of the company or customer, often where the rule or standard is perceived as counterproductive. In the case of corporate or charter flying, it’s the argument that the passenger shouldn’t have to (or doesn’t want to) wait. I’ve seen examples of pilots starting engines while the passengers are still boarding, or while the copilot is still loading luggage. Are we at war? Under threat of physical attack? Is there some reason a 2 minute delay is going to cause the world to stop turning?
  
• The last step in the process is silence. Co-workers are afraid to speak up, and understandably so. The cockpit is already a small place. It gets a lot smaller when disagreements start to brew between crew members. In the case of contract pilots, it may result in the loss of a regular customer.  Unfortunately, the likelihood that rule violations will become normalized increases if those who see them refuse to intervene.
  
  

The normalization of deviance can be stopped, but doing so is neither easy or comfortable. It requires a willingness to confront such deviance when it is seen, lest it metastasize to the point we read about in the Bedford NTSB report. It also requires buy-in from pilots on the procedures and training they receive.  When those things are viewed as “checking a box” rather than bona fide safety elements, it becomes natural to downplay their importance.

Many of you know I am not exactly a fan of the Part 121 airline scene, but it’s hard to argue with the success airlines have had in this area.  When I flew for Dynamic Aviation’s California Medfly operation here in Southern California, procedures and checklists were followed with that level of precision and dedication.  As a result, the CMF program has logged several decades of safe operation despite the high-risk nature of the job.

Whether you’re flying friends & family, pallets of cargo, or the general public, we all have the same basic goal, to aviate without ending up in an embarrassing NTSB report whose facts leave no doubt about how badly we screwed up.  The normalization of deviance is like corrosion: an insidious, ever-present, naturally-occurring enemy which will weaken and eventually destroy us.  If we let it.

Disturbing reading but with some real lessons to be learnt from..

Shame on the ATSB & CASA for continuing to O&O the PelAir investigation (now re-investigation), as the lesson of risk mitigating 'normalised deviance' in an operational aeromedical environment could & should have been learnt for the benefit of all industry stakeholders - SHAME!


MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - Gobbledock - 03-28-2016

Is there a rogue in the house?

P2, you mentioned;

"Tony Kern also documents this phenomenon in the military with his book Rogue Pilot".

IMO "Darker Shade of Blue" is one of the best books on Human factors you will read. It was also written at a time when HF was not as commercially understood or applied as it is today. If ever you get a chance to attend one of Kern's lectures I highly recommend it. Money well spent and time well allocated, unlike attending one of the group masturbation and cucumber sandwich eating sessions promulgated by Skidmore and his band of pony pooh peddlers.

Of interest is the 'rogue' concept which doesn't only apply only to pilots, it also applies to organisations, CEO's and Regulators. Each of these areas can and does have rogue elements operating within them where normalised deviation becomes the norm, it becomes the standard, an accepted practise. A close examination of CAsA, it's history, it's half-baked approach to safety and procedures as well as it's comical legacy of bullying and malfeasance shows a normalised deviation to what it has deemed to be a normal regulatory behaviour, a mentality that has existed and flourished for decades. As a result there have been many accidents and deaths that can be attributed back to this 'rogue' mentality by the Regulator.

One day we may have a Regulator staffed, managed and oversighted not by bench warmers being rewarded for their years of kissing military and political ass, not by lazy sods filling in their last few years topping up their super funds and semi retiring on the taxpayer funded payroll, and not by sociopaths and pyscophants with small dicks who are pussy whipped at home. No we may have skilled, industry learned aviation folk who have earned their trade in a stalled Metro at low altitude, or by stripping down a Lycoming while wearing a blindfold, or skilled pilots penning operations manuals and the like in clear, succinct, workable and sensible fashion, minus the legalese and other such bollocks..........

So be it, that concludes my Monday twiddle. So as to not deviate from standard operating procedures I shall now brew a fresh pot of black, take my four legged companion for a wander around the community and then I shall lay back and bask in the afternoon sun as it beckons me to put down my book and take a quick flight around the block.

GD

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 04-06-2016

Normalised deficiency continued - The following is another classic example of an ND accident, this time however in a maritime environment but the lesson is still the same.

"Over time we deviate a little from written standard operating procedures, and nothing bad happens. Until it does."

Courtesy of the excellent Inner Art of Airmanship Blog -

Quote:Procedural drift and the sandbar

By Dave English

On 3 January 2015, the large ship MV Hoegh Osaka left the British port of Southhampton. An hour later she turned to port, and began listing markedly to one side. Soon enough the rudder and propellor were out the water. Fifteen minutes after the turn she was grounded on the Bramble Bank sandbar off the Isle of Wight. Settling down with a list that would eventually reach 52°. The ship was about half full, loaded with 1,200 Jaguar and Land Rover vehicles worth over $45 million.



Now, this accident isn’t as serious as the Titanic (which also left from Southhampton), here everybody lived. But this was just last year. A Japanese-built modern ship. Good weather, certainly no icebergs. Ship under the control of a Southampton pilot. Leaving a busy international port with over two thousand years of continuious use, a traditional hub of British sea power and commerce.

The pilot wasn’t drunk. There was no terrorist plot. No failure of machine. No rogue wave. So how did this happen?

The respected British Marine Accident Investigation Branch (MAIB) released their report this month. Their key finding is:

Quote:“No departure stability calculation had been carried out on completion of cargo operations and before Hoegh Osaka sailed. Witness and anecdotal evidence suggests that this practice extends to the car carrier sector in general. The fundamental requirements for establishing before departure that a ship has a suitable margin of stability for the intended voyage had been eroded on board Hoegh Osaka such that unsafe practices had become the norm.”

In flying terms, the weight and balance calculations were not done. (Mass and balance is the more correct term, I was a physics major, but I digress.) The ship was not stable in a tight turn. It turned, and listed, and could not recover. If it ‘departed controlled flight’ we might say.

This was not a one-time slip or error or mistake. This was apparently common industry practice. It was so common that unsafe practices had become the norm.



We call this procedural drift; it’s the unintended, systematic adaptation of routine practice from written procedure. We saw it in the Space Shuttle Challenger accident, the friendly fire shoot-down of two US Black Hawk helicopters, the Deepwater Horizon drilling rig, and many other events. In The Field Guide to Understanding Human Error Prof. Sidney Dekker lists several potential reasons for procedural drift:

• Rules or procedures are over-designed and do not match up with the way work is really done.
  
• There are conflicting priorities which make it confusing about which procedure is most important.
  
• Past success (in deviating from the norm) is taken as a guarantee for safety. It becomes self-reinforcing.
  
• Departures from the routine become routine. Violations become compliant behavior with local norms.
  

Over time we deviate a little from written standard operating procedures, and nothing bad happens. Until it does.

Quote:“Witness and anecdotal evidence suggests that the practice of not calculating the actual stability condition on completion of cargo operations but before the ship sails extends to the PCC/PCTC sector in general. For reasons of efficiency, what is a fundamental principle of seamanship appears to have been allowed to drift, giving rise to potential unsafe practices.”

We’ve all seen it. We’ve all done it. But we are repeatedly amazed when an incident happens. This week Lloyds List Intelligence said about the accident:

Quote:“Two things are infinite: the universe and human error.”

I’m not sure about the physics of the first part, but it does make for a good headline! The potential danger of these kind of errors should be well-known as stability incidents have happened before on sea-going car carriers, such as the Cougar Ace, Tricolor and Baltic Ace. Lloyds continued to say:

Quote:“The report found shortcomings in training, procedure and crew attitude that suggest the myriad contributory factors to this casualty have occurred individually on many other sailings.”

“Rather than a freak occurrence from a catastrophic failure, the incident looks to be a statistical inevitability. When small risks are occasionally or routinely accepted in multiple areas, there will eventually come a time when those risks all conspire to become something much more significant.”

The sands of time ran out for the MV Hoegh Osaka on the Bramble Bank sandbar. So, is the clock ticking on your weight and balance calculations? Do you ever takeoff ‘just 10 pounds’ overweight? Or skip some takeoff performance because you’ve safely done it just like this a hundred times before?

Is it time to check the drift?

Excellent stuff, let's hope the ATSB PelAir re-investigation review the organisational issues and the NDs involved -
MTF...P2  

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RE: Closing the safety loop - Coroners, ATSB & CASA - P7_TOM - 04-13-2016

From Ben Sandilands blog  - Plane Talking, on Crikey:-

Nothing can excuse the Albury Virgin ATR safety fiasco, not even this latest piece of ATSB fluff.

The rest of the article – HERE – is worthy of consideration and discussion.

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ ~ ~ 

Mountains to Molehills – ATSB style.

When this ‘incident’ first came to light there were serious questions raised, to which ATSB has not deigned to investigate or answer.  The aftermath – 13 passenger flights – are not the aberration, but a resultant of the first in a series of events which remain firmly ignored, unmentioned and; not, as yet addressed.  

In short; the root cause of the initial ‘problem’ remains unresolved.  The ATR has a facility which allows the two normally interconnected flight control systems (yokes) to be disconnected and operate independently.  This in case a manual flight control channel is lost.  With a significant amount of opposite direction pressure from the other yoke, (e.g. one pulls up, ‘tuther pushes down) the two flight control systems may be separated.  This event occurred during a ‘routine’ descent to approach at Sydney, with no noted flight control problem.  The potential for stress and damage caused by opposing control inputs, from two viable systems should have engineering alarm bells ringing, demanding serious, in depth inspection.  It did not.  The controls were simply reconnected, a cursory inspection conducted and the aircraft returned to service; for the remaining 13 flights.

In other accident events ATSB have played the accompaniment to the CASA preconceived notion, Canley Vale and Pel-Air for example.  Where ATSB report supported a stern, rapid prosecution of pilots and operators, through to Coroners court, where required.  There are some very serious incidents still on the books at the moment related to turbo-prop powered aircraft – Moranbah and the Newcastle coal loader incident for example; there are some serious, outstanding heavy jet transport incidents, such as Perth and Mildura which are still patiently awaiting their ATSB final report.

If we are serious about ‘safety’ the minister, the government and travelling public need to get over the bi-partisan system of relying on ATSB and CASA to ‘sort it’ and start demanding changes to the way our ‘aviation watchdogs’ set about doing their expensive business.  But, enough said it.   All been said before, and precious little changes.  But gods help the government in power when the unthinkable happens and a Royal Commission is demanded. 

The time is now, to get our aviation safety house in order, before we run out of dumb luck.

When 'Darren' is standing looking down into a smoking hole, filled with body parts, will he have a hair out place then? - Big money says not.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 07-27-2016

Regulator envy - FAA practicing what they preach.

Recently Christine Negroni published the following article on the less than impressive safety culture of US Allegiant Air:

Quote:Allegiant’s Record No Indicator of Safety
July 18, 2016 / Share your comments...


Credit to Paige Kelton of Jacksonville’s WJAX-TV, for doing the heavy lift and reviewing 2,400 pages of FAA incident reports on Allegiant Air. In her report last week, Kelton reveals that the documents show seventy-six flights into Florida over a two year period had safety issues grave enough to require they be reported to the feds.

Where I’ll argue with the report is in the conclusion of her safety expert who credits the pilots for the fact that the airline hasn’t had any fatal accidents.

Allegiant’s pilots may be fantastic but attributing the lack of a catastrophe on the flight crew is a two edged sword. When disaster arrives will the pilots be to blame?
An Allegiant 757 in Honolulu

Anyone with a passing interest in air safety understands that an accident is a series of events. Remove one and it doesn’t happen. When news stories or talking heads diminish this complexity they risk turning the folks in the pointy end into heroes or demons. Rarely are they either, though they are always important, integral parts of a safety system.

The FAA has been doing a 90 day review of Allegiant after a number of headline-making events over the past few years including the embarrassing case of Allegiant Flight 426 with two management pilots in command. The crew failed to notice the temporary closure of Fargo’s Hector International for a Blue Angels air show but were so low on fuel, they had to declare an emergency and land there despite the TFR.

What has already emerged in news accounts and in private comments made to me and to others, is that the penny-pinching that has made the low-cost carrier one of the nation’s top performers is a technique also employed on the backside of the airline.

Safety is viewed as an expense not an investment in the airline’s future, one former employee told me. The cavalier approach to doing things the right way will lead to a “catastrophe” I was told.

Emergency evacuation of an Allegiant flight. Photo courtesy Bryan Dougherty

So Kelton’s deep dive into the gritty details, the smoke events and the navigational problems, the flight cancellations and the diversions is an important story, ratifying the FAA’s decision to do its own deep dive.

If this extra scrutiny convinces the airline to change its ways and give safety the priority it deserves, the very best result will be that Allegiant maintains its status as never having had a fatal accident.

But it cannot say it didn’t push its luck far longer than it should have.

    
And in follow up to that the JDA Journal today reports on the outcome of the FAA 90 day review of Allegiant Air:

Quote:Allegiant & Compliant are now Congruent?


Posted By: Sandy Murdock July 26, 2016

FAA’s Compliance Philosophy In Effect With Allegiant

Well over a year ago, the FAA made a seismic change in its basic regulatory regime. Since the creation of the FAA, the safety agency used the fear of sanctions and public embarrassment to compel the airlines to adhere to its rules. The Administrator last summer established a new path emphasizing collaboration, cooperation, compliance and immediate solutions to existing problems. There was some reason to doubt whether the field inspectors and lawyers would follow this pronouncement from on high. The institutional imperatives (diminishing Congressional funding, inability to match old enforcement techniques with staffing reality, SMS’s emphasis on trust in working together) compelled that the new philosophy must work.


During that same time period, the long history of a contentious relationship with Allegiant made the resolution of pending “enforcement” cases into a test of the acceptance of the Huerta approach. There have been a number of statements which did not appear to be in congruence with the SMS/Compliance approach.

On July 18 the news included language suggesting that the FAA personnel involved in the surveillance of Allegiant are on board with the new approach:

“An FAA spokesman said the evaluation, which every airline must undergo every five years, uncovered ‘a number’ of deficiencies. ‘None were systemic regulatory problems, which are the most serious category of deficiencies identified in these types of reviews.’ He said the FAA will ‘closely monitor’ the effectiveness of Allegiant’s mitigations, which are due by Sept. 30.

The FAA has determined that the findings don’t warrant enforcement action at this time.”
[emphasis added]
That’s the language of the new Philosophy; cooperation and compliance, not the ticket-writing jargon of the past.

While that’s a clear positive movement towards the Huerta approach, the next critical inspection point will be the follow up by Allegiant no later than September 30 when it will be determined if the carrier aggressively addresses the agency’s finding PLUS soon thereafter when the FAA replies.

See what I mean by 'regulator envy' -
MTF...P2.

(Pardon me) - Yup; but I can also hear McComic grinding his teeth and salivating during his dream cum true, once in lifetime opportunity to do some real damage.  The question is – which path will OST take, Nirvana or Perdition?  Bravo FAA, bravo and well done. Tt.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 08-05-2016

Aviation safety: The auto-dependency spectrum??

Opposite ends of the spectrum? - Duck'n'dive:

Quote:Flight below minimum permitted altitude involving Cessna 441, VH-EQU

Near Wollongong Airport, New South Wales, 3 August 2015

Versus...well duck'n'dive??    


Courtesy Flight.org blog...

Quote:
11
Oct
SHEED, MESEN and Melbourne’s RW34. A Look Back at Virgin Australia’s Boeing 777 Flight Path Incident.
4 comments -

It’s been a little over 12 months now since the ATSB were informed of an incident involving a Virgin Australia Boeing 777 and an unstable approach to Runway 34 at Melbourne (YMML, MEL). Given the impending update from the ATSB, now is a good chance to reflect on the incident before the final report is published.

This article seeks to uncover a means in which to mitigate occurrences of similar unstabilised approaches elsewhere, and we’ll also compare the procedure as flown on the Boeing 777 to that of the Boeing 737 (for which similar incidents are a rarity).

Today in the Australian, international aviation safety legal expert, Joseph Wheeler is back with yet another thought provoking article, this time in relation to the Emirates crash landing in Dubai - see HERE for the latest on AP on the developing story on this accident:

Quote:Emirates EK521 Dubai accident puts focus on autoflight systems

• Joseph Wheeler
  
• The Australian
  
• 12:00AM August 5, 2016
  

It may be too early to narrow down the causes that contributed to the destruction this week of an Emirates Boeing 777 aircraft in Dubai, but aspects of the accident warrant attention given similarities with others in recent years.

The event bears at least a superficial resemblance to the crash of Asiana Airlines flight OK214 at San Francisco Inter­national Airport on July 6, 2013.

There, a variant of the Boeing 777 family crashed on landing due to a mismanaged approach. ­According to the US National Transportation Safety Board, certain safety issues were identified which contributed to the disaster.

If initial reports are correct — that Emirates flight EK521 was attempting a go-around or missed approach when it landed on its belly — then many of the matters implicated in OK214 could be relevant to this latest incident.

Among these factors are the design complexity of the 777’s auto­flight system. The NTSB recommended that reduced design complexity and improved systems training could help reduce the type of errors made by the pilot flying in the Asiana crash.

Other findings indicate there was an overuse of automation at Asiana. The US aviation regulator has since introduced guidance and a regulatory change to support the need for pilots to regularly perform manual flight so their skills do not deteriorate.

It will be interesting to note as an Emirates investigation proceeds, whether this issue was considered to contribute to the EK521 events and whether UAE laws and guidance were amended when the US FAA rules were amended.

The only casualty in the Emirates accident was a firefighter. How did someone who helped save so many following the evacuation of EK521 come to lose his own life in the process?

While no firefighters died in their response to the Asiana crash, one passenger did when the firefighting crew failed to check for vital signs of a Chinese teenager and subsequently drove over her.

One of the NTSB recommendations was that officers placed in command of an accident be given aircraft rescue and firefighting (ARFF) training.

The arriving incident commander placed an officer in charge of the fire attack for OK214 who had not received ARFF training, and this was considered to have introduced unnecessary challenges.

There was, in fact, no guidance in place or protocol to ensure the safety of passengers and crew at risk of being hit or driven over by a vehicle during ARFF operations.
Among contributing causes in the Asiana crash, according to the NTSB are “(1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing’s documentation and Asiana’s pilot training … increased the ­likelihood of mode error …” and “(5) flight crew fatigue which ­likely degraded (the pilots’) performance”.

In light of media reports after the Flydubai accident at Rostov-on-Don, Russia on March 19 that implicated pilot fatigue as a contributing cause, this factor will also be watched with interest by the aviation industry following the events that led to EK521’s destruction.

As recently as this week British media published leaked documents from Flydubai pilots suggesting they were unsafely urged to work beyond their flight and duty time limitations even when they had warned their employers it would be unsafe.

All eyes will be on the outcome of a UAE General Civil Aviation Authority investigation into EK521 with professional interest, to see if fatigue played a role.

Joseph Wheeler is the principal of aviation and aerospace law firm IALPG and aviation counsel to Maurice Blackburn lawyers and the Australian Federation of Air Pilots.

Of course it is all idle speculation at this stage but JW does bring into the mix some very interesting observations on the possible liability issues associated with these high profile accidents, where it can be shown that the relevant authorities have not taken on-board or proactively risk mitigated identified safety issues from past accident investigations.

Also of interest, & perhaps another potential hole in the Swiss cheese, with the Dubai Emirates accident is again a Flight.org article which Ventus linked to in the AP 'Accidents - Overseas' thread mentioned earlier:

Quote:
12
Apr
Low Missed Approach Altitude Restrictions
2 comments

A question concerning a recent change to the missed approach procedures in Dubai UAE (OMDB) has raised some interesting points about the 777 in this flight regime: high thrust, low altitude, high pilot workload, and ATC procedures that would seem to be not too well thought out.

  
Not that our pollies or bureaucrats seem to give a toss but in the interests of 'closing the safety loop' and mitigating safety risk, on what seems to be re-occurring modern day international aviation safety issues, perhaps we need to identify where we (Australia) sit on the auto-dependency spectrum...
MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - ventus45 - 08-05-2016

In the interests of brevity, it is merely reaping what you sow.
The AIOS harvest is more and more looking like a bumper crop in the making.
The stats are adding up, one by one.

Perhaps we need a new "specific" category of incidents and accident.

"AIIA's" = Automation INDUCED Incidents and Accidents"

As someone is very fond of saying: Tick - Tock.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Gobbledock - 08-05-2016

Solemn reflections while out walking in the forrest

What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly.

The 80's was the decade of midair crashes. TCAS was introduced in the late 80's into the early 90's and again with outstanding results. Problem identified and problem solved, mostly.

The 80's and early 90's was also quite a popular time for weather related accidents, particularly windshear, and Windshear, Detection and Alerting Systems underwent a technological improvement that has seen countless accidents avoided. Problem identified and problem solved, mostly.

The 2000's has seen two trends. Firstly runway overruns became more popular than a Politician at a trough. Very popular. The second has been runway incursions and accidents. Asiana's 777 at San Fran landing short in 2013 is memorable, FlyDubai earlier this year eating pavement was truly disturbing and now the EK crash. It's too early to fully speculate on the EK crash although some likely causes are starting to shine through. I will leave that to other discussion threads. No two accidents are the same, so you can't necessarily group all of these airport/runway accidents together under one root cause, however my observations indicate that there could be two causes or contributing factors to numerous airport/runway accidents in the past 15 years;
1) Growth in air traffic and airport usage at select airports and their associated airpsace.
2) Operational pressure;
- Budgets budgets budgets! Pilots pressured to remain on schedule and not cause 'financial penalties' due to performing go-arounds, hence pushing the envelope.
- Pilot fatigue due to companies squeezing more out of them.
- Poor and/or degrading airport infrastructure due to a lack of dedicated finances.
- High oil costs for many years and tight profit margins which in turn puts pressure on pilots to save costs.
- Cutbacks to training program's, SIM time, even some Pilots lack of flight hour experience in the larger commercial jets.

Anyway, that's my two-bob worth. I could be wrong, and after all I am just an ageing old man. But I do know one thing - unless the EK aircraft was in a really really unstable config it is a brave crew who hit the joystick while sinking at a reasonable rate of knots over very low altitude right above the piano keys in 50 degree weather.

"Safe sandpits for all"


#bringbackalan

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 08-16-2016

(08-05-2016, 08:09 PM)Gobbledock Wrote:  Solemn reflections while out walking in the forrest

What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly.

The 80's was the decade of midair crashes. TCAS was introduced in the late 80's into the early 90's and again with outstanding results. Problem identified and problem solved, mostly.

The 80's and early 90's was also quite a popular time for weather related accidents, particularly windshear, and Windshear, Detection and Alerting Systems underwent a technological improvement that has seen countless accidents avoided. Problem identified and problem solved, mostly.

The 2000's has seen two trends. Firstly runway overruns became more popular than a Politician at a trough. Very popular. The second has been runway incursions and accidents. Asiana's 777 at San Fran landing short in 2013 is memorable, FlyDubai earlier this year eating pavement was truly disturbing and now the EK crash. It's too early to fully speculate on the EK crash although some likely causes are starting to shine through.

I will leave that to other discussion threads. No two accidents are the same, so you can't necessarily group all of these airport/runway accidents together under one root cause, however my observations indicate that there could be two causes or contributing factors to numerous airport/runway accidents in the past 15 years;

1) Growth in air traffic and airport usage at select airports and their associated airpsace.
2) Operational pressure;

- Budgets budgets budgets! Pilots pressured to remain on schedule and not cause 'financial penalties' due to performing go-arounds, hence pushing the envelope.
- Pilot fatigue due to companies squeezing more out of them.
- Poor and/or degrading airport infrastructure due to a lack of dedicated finances.
- High oil costs for many years and tight profit margins which in turn puts pressure on pilots to save costs.
- Cutbacks to training program's, SIM time, even some Pilots lack of flight hour experience in the larger commercial jets.

Anyway, that's my two-bob worth. I could be wrong, and after all I am just an ageing old man. But I do know one thing - unless the EK aircraft was in a really really unstable config it is a brave crew who hit the joystick while sinking at a reasonable rate of knots over very low altitude right above the piano keys in 50 degree weather.

"Safe sandpits for all"


#bringbackalan

Closing the safety loop #34 - Gobbles said:

"..What is interesting is that the 70's was the decade for CFIT. The GPWS was introduced. It made an incredible difference and improved safety. Problem identified and problem solved, mostly..."

On the subject of the introduction & history of GPWS, I note the following excellent article from Bloomberg on the man who invented that life saving technology...

Quote:Thanks to This Man, Airplanes Don’t Crash Into Mountains Anymore

The wreckage of Alaska Airlines Flight 1866, a Boeing 727, smolders as recovery workers search for the bodies of 111 victims on Sept. 7, 1971, in Juneau, Alaska.
Photographer:AP

Don Bateman’s terrain mapping device has nearly eliminated the largest cause of death in jetliner accidents.

By Alan Levin | August 10, 2016

Giant flocks of black birds circled the wreckage of an airliner that had struck an Alaska mountain two weeks earlier, killing all 111 aboard. In a small plane overhead, a young engineer directed his pilot to follow the same path the jet had taken toward the craggy terrain.

With seconds to spare, an alarm went off. Don Bateman’s plane climbed to safety, but he was frustrated. The electronic device he invented to warn pilots that they were about to hit the ground didn’t leave enough time to have prevented the large airliner from crashing.
“I was disappointed,” Bateman, now 84, recalled of the day in 1971 when he flew over the remains of Alaska Airlines Flight 1866, which had slammed into a fog-shrouded ridge. “We needed to do better.”

That’s exactly what Bateman and his small team of engineers at what is now Honeywell International Inc. did. The device presaged today’s mobile mapping applications, dramatically reduced what had been by far the worst class of air crashes and made Honeywell billions of dollars.


Don Bateman with a Honeywell plane the company used to test his safety devices at Paine Field in Everett, Wash.
Photographer: Mike Kane/Bloomberg
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“I would give Don individual credit for having saved more lives than any other individual in the history of commercial aviation,” said Earl Weener, a member of the U.S. National Transportation Safety Board and former chief engineer for safety at Boeing Co.

Before retiring in June, Bateman and his band of colleagues dabbled in the world of Cold War espionage, hid the true cost of their endeavor from their corporate masters and endured skepticism from the very airlines whose planes were being lost. In spite of repeated changes in corporate ownership and the blunt-spoken Bateman’s occasional threats to quit, he worked on his mission to save lives with the same group for almost six decades, colleagues said.

Eventually Bateman’s Enhanced Ground Proximity Warning System became required in most commercial planes around the world, dramatically reducing accidents in which perfectly good aircraft with trained crews plowed into the ground or bodies of water, almost always in poor visibility.

In the 1960s and 1970s, there was an average of one such fatal accident per month, according to the AviationSafetyNetwork website. It was by far the largest cause of death in jetliner accidents.


President Obama awards Bateman the National Medal of Technology and Innovation in 2011.
Photographer: Win McNamee/Getty Images

Since the U.S. government began requiring an upgraded version of the device on all but the smallest aircraft starting in 2001, there hasn’t been a single such fatal crash on a U.S. commercial passenger plane equipped with it or competing devices. There have been a few overseas, often when pilots ignored or shut off the devices.

President Barack Obama awarded Bateman the National Medal of Technology and Innovation in 2011.

Bateman was always fascinated with airplane crashes. As an 8-year-old school boy in 1940 in Saskatoon, Canada, he and a friend sneaked out of class after two military planes collided and crashed nearby. As punishment, his teacher made him write a report on what happened.

“That was my introduction to aircraft accidents,” he said recently. The carnage he saw that day helped motivate him years later.

After taking a job with Boeing in Seattle, he joined a small aviation firm called United Control in 1958. Airplane accidents continued to fascinate him and he began “making little books” of notes on them. One type stood out.

In the arcane world of aviation terminology, these crashes were called Controlled Flight into Terrain, or CFIT. It was a vexing problem: Basic navigation should have kept pilots from crashing. But the cockpit navigation technology of that era wasn’t intuitive and it was too easy to get disoriented, especially at night or in bad weather.

“In my mind it became a big issue, even though there wasn’t much being done about it,” Bateman recalled.

In the 1960s, Bateman worked with Scandinavian Airlines System, now SAS AB, which had suffered a CFIT crash in Turkey in 1960, to invent a mechanism to warn pilots when they flew too low. It involved a new instrument on planes that used radio waves to determine a plane’s distance from the ground. It helped stem the accident rate and, after a series of crashes, the U.S. Federal Aviation Administration required it starting in 1974.

But it was prone to false alarms and had a glaring weakness: It couldn’t look forward, so was of little use if a plane was flying toward steeply increasing ground, such as a mountain.

For years, Bateman tinkered with the device to improve it. He also consulted with NTSB investigators, poring over accident reports.

“He would come to me and say what do we know about this accident?” said Jim Ritter, director of the NTSB’s Office of Research and Engineering, who was a technician at the time. “The whole time, the gears were spinning and he was trying to make things safer.”

Bateman had been imagining a far better solution as early as his flight over the Alaska crash site. If he could create a database of all the world’s terrain, the device would see mountain tops and cliffs from miles away. But this was before personal computers and global-positioning services.

Even worse, much of the world’s topography was considered secret at the time, a vestige of the Cold War.

Then in 1991, in the chaos created by the breakup of the Soviet Union, the detailed maps it had created of the world starting in the 1920s were for sale -- if you knew where to buy them.

Bateman asked Frank Daly, the director of engineering at the Sundstrand Corp. division that had swallowed United Control, for his blessing to purchase the data from the U.S. government’s Cold War enemy.

“He thought I was crazy,” Bateman said.

They wound up sending one of his employees, Frank Brem, in search of maps in Russia and elsewhere. “There isn’t a terrain data store in downtown Moscow,” Daly recalled. “But he would go out and find the right people.”

A bigger problem than navigating the black market was the millions of dollars it was costing for the still unproven technology. “We probably weren’t as open with senior management about that process,” Daly said. He sometimes hid costs in other accounts.

A demonstration of a prototype infrared technology from Honeywell at Morristown Airport in New Jersey in 2010.
Photographer: Emile Wamsteker/Bloomberg

By the early 1990s, Bateman had developed working prototypes of the new system. Now the company had to sell it.

For pilots and safety officers, it was a marvel. Ed Soliday, then director of safety at United Airlines, had been prodding Bateman to improve the warning device. One day in the early 1990s, Bateman called and said he thought he had what Soliday wanted.

“Once I flew the thing with Don, it was like an epiphany,” Soliday recalled. “I was sold. I thought if we could make it work, this was a huge breakthrough.”

If a plane was flying toward a mountain, a screen popped up automatically marking the high ground in yellow and red on a map. If pilots didn’t respond, it began a series of increasingly dire warnings. Once a collision became almost imminent, a mechanical voice implored, “Terrain, terrain. Pull up! Pull up!” Compared to the earlier system, it was almost fool proof.

There are 45,000 units on aircraft today, worth more than $4 billion at list prices
But many of the more cost-conscious corporate chieftains at airlines weren’t convinced, according to Bateman and Daly.

A meeting at American Airlines was particularly grim. Daly was on the sales call at the airline’s headquarters with his then chief executive officer. Their host, a senior executive at the airline, was hostile.

“He was almost apoplectic and said, ‘We don’t want another box. We don’t want to have to replace the existing system,’ ” Daly said. “Here I am justifying spending tens or hundreds of millions of dollars and my boss has just been soundly beaten on the shoulders by the customer.”

Soliday had more success at United. The airline agreed to help Bateman’s team test it so it could be certified by the FAA, he said. Most other carriers balked. It took another high-profile fatal crash to change their minds.

What the Pilot Sees
The current version of Bateman’s device, Honeywell International Inc.’s Enhanced Ground Proximity Warning System, uses a color-coded map display to show pilots where dangerous high ground lurks ahead. Hazards grow in danger from yellow to red. A solid red area means a collision will occur within 30 seconds if pilots don't act. The device also has warning horns and can instruct pilots to “pull up!” in an emergency.

As American Flight 965 neared Cali, Colombia, from Miami on the evening of Dec. 20, 1995, a pilot accidentally entered the wrong data into the plane’s flight computers. The crew didn’t notice as it began a slow left turn toward mountains lying invisible in the darkness.

The Boeing 757 was equipped with the earlier version of Bateman’s warning device and its mechanical voice began warning of “terrain.” But 13 seconds later, after the pilots added full throttle to climb as steeply as possible, it rammed into a ridge. All but four of the 163 people aboard died.

Within days the airline wanted the new device, which would have issued an alert far earlier and likely prevented the crash, Bateman and Daly said. First American and then United agreed to voluntarily install them. Other carriers followed. The FAA began requiring them in 2001.

In the end, the products spawned by Bateman’s device were a financial boon to Honeywell. There are 45,000 units on aircraft today, worth more than $4 billion at list prices, according to the company.

Both Bateman and Daly wonder whether the decades-long effort to develop and improve the warning system would be possible in today’s risk-averse corporate world.

“Today new projects need to be blessed by many people,” Daly said. “You need to have hard evidence. They just would not speculatively fund something like this, especially when we were being resisted by the aircraft manufacturers, the airlines.

“But Don’s faith, the genius of his team and a little support from the company -- and it happened.”

As Gobbles alludes in his post the introduction of lifesaving risk mitigation technology, like GPWS & TCAS, was due in large part to many findings & safety recommendations from effective AAI (Aviation Accident investigation) as per ICAO Annex 13 throughout the 70s, 80s & early 90s. Since that time we've seen the onset of safety issues revolving around automation dependency. Subsequently there has been many proactive safety recommendations attempting to mitigate this now repetitively identified safety issue.

Unfortunately in Australia our State AAI, the ATSB, is yet to clearly identify 'automation dependency' as a significant safety issue in modern day 'next generation' RPT aircraft.  

Quote:SafetyWatch

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. The ATSB Commission urges the transport community to give heightened attention to the risk areas featured below. These are the areas where Australia’s aviation, rail and maritime communities can make safe transport systems even safer. 

SafetyWatch gives you information about each safety concern, strategies to help manage risk areas along with links to safety resources. 

The ATSB will add or remove topics over the coming months to reflect current information on safety trends and occurrences. 

Subscribe now to keep up-to-date with news from the ATSB or follow us @ATSBinfo on Twitter. 
 
Click on a photo for more information.

 

Related: SafetyWatch
 

This is despite the quite disturbing findings in previous Senate Inquiries like:
Pilot training and airline safety; and Consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010
&..
Aviation Accident Investigations
The former inquiry, at Recommendation 9, actually called for the relevant agencies to review the findings & recommendations to come from the AF447 Final Report:

Quote:2.299    The committee recommends that the Civil Aviation Safety Authority (CASA), the Australian Transport Safety Bureau (ATSB) and Australian aviation operators review the final findings of France's Bureau of Investigation and Analysis into Air France 447, including consideration of how it may apply in the Australian context. Subject to those findings, the committee may seek the approval of the Senate to conduct a further hearing in relation to the matter.

However like the vast majority of well considered Senate & Government non-partisan review findings, these potential risk mitigation recommendations were completely ignored by CASA, ATSB, Airservices Australia & Murky's department.
Therefore rather than being at the forefront in aviation safety, Australia is now severely lagging behind the rest of the world and in some cases our aviation safety agencies are consistently becoming part of the causal (Reason model) chain...
Shame on you Malcolm, Barnbaby & miniscule 4D Chester, shame!
MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 09-02-2016

CAsA & ATsB out of the loop on RPA/UAV safety -

Remember this??


This was the QON & the ATSB somewhat flippant answer:

Quote:Senator Fawcett, David asked:

Senator FAWCETT: … Early this year just north of Perth a Dash 8 had a very near miss with a reasonable-sized UAV. I understand ATSB has made comment on that incident. But, more broadly, the question I am interested in is how many incidents are being reported to you through the various reporting mechanisms that you have, whether it is micro or larger UAVs. Secondly, what input, if any, are you having into the current NPRM that CASA has on the streets around looking at new rules for UAV operations?

Mr Dolan: The first half of your question I think we would have to take on notice, unless someone has the material in front of them. But we are tending to look at all significant events involving UAVs, just because it is one of those growing territories, at least to some establish-the-facts sort of level. I would have to consult with my colleagues to establish what we have been doing with CASA on the specific question of their new rule suite.

Senator FAWCETT: I am happy for you to take that on notice. I would also like you to take on notice ATSB's position, with the breakdown of incidents that have occurred—just from what I have seen in the media, the majority appear to be the smaller UAVs that your amateur can buy from whatever kind of shop—on the concept that anything less than two kilograms essentially does not present a risk and therefore should be unregulated, and whether in the light of incidents that have occurred you are comfortable with that approach.

Mr Dolan: I am happy to give you a response on notice.

…

CHAIR: Then will you come back to the committee—or through the secretary or through the department or through the minister—and explain to the Australian public and this committee what their protection is from the growing plethora of unmanned vehicles in the air?

Answer:

The ATSB has received 19 reports relating to UAVs over the last 3 years (although two may have been model aircraft). Twelve of these were medium (2 to 150 kg), one was small (150g to 2 kg) and six are unknown (likely to be either small or medium).

The ATSB received a briefing on the NPRM at the last ATSB/CASA Bi-annual meeting on 4 June 2014. The ATSB did not consider it necessary to make a submission on the NPRM.

The types of incidents reflect manned aircraft incidents (apart from i & vi):

i. 5 datalink/communication failures

ii. 5 engine failures

iii. 1 airframe failure

iv. 1 birdstrike

v. 3 near collisions with aircraft (two of these may have been model aircraft)

vi. 1 collision with a person resulting in minor injuries

vii. 2 UAV operating in a CTAF without making calls and/or in circuit area

viii. 1 UAV operating near a controlled aerodrome outside VMC

Refer to SEQoN 236.

 
And this was where we last left the vexed issue of UAV/RPA regulation on Aunty Pru:

(07-08-2016, 03:29 PM)Peetwo Wrote:  

(07-07-2016, 11:40 AM)kharon Wrote:  Drones and the like.

This topic is getting some traction, particularly now with ‘sales’ expected to increase 10 fold.  It got some attention at the BRB last evening.  It’s not a ‘hot’ topic, not yet at least, but the different ‘styles’ of risk management were discussed. The FAA appear to be taking a strong line, registration and airworthiness checks, CASA a more laid back approach where responsibility is abrogated through the familiar hand washing process. One of the almost unanimously agreed points was that no matter what the official approach taken, the ‘rogue’ element and those who wilfully intend to misuse the UAV will do so, regardless.

The conversation then turned to ‘numbers of’ – in the long term.  Just how many of the wretched things can we expect.  Consensus seemed to be that at the moment, it’s a ‘fad’ which will hit a peak and diminish as interest wains and wrecks increase.  Sensible money seems to be bet across a three horse race; the sane, safe, legal productive use of an excellent tool by responsible adults: the dedicated aero-modeller types who have never yet created a problem to anyone; and, the dedicated Darwin award crowd who also like lasers and spotlights.  The also rans are those who will purchase not a tool or a thing of interest but a trendy ‘product’ to amuse ‘junior’ for a while until it is discarded and finds it’s way into the nearest skip, broken and forgotten as easily as it was purchased.

One thing was agreed, UAV’s are here to stay in one form or another; it only remains to be seen how ‘government’ will respond – after the fact with retrospective knee-jerk; or, proactively looking carefully at the risks.

We shall see – for mine, the shotgun is always handy.

Toot toot.

Hmm...I'm a little bit dubious of this...

"...Australia can be confident that the biggest aerial innovation since the jet engine is being introduced safely and deliberately. Nobody knows this better than CASA — and when CASA promotes the benefits of more commercial micro drones in Australia, we should all listen..."

From his track record so far Skidmore has shown no inclination to giving a flying fig (or UAV) for minority industry groups and/or their commercial concerns, it is simply not part of his vocabulary -   

Moving back to the Gold Coast incident two days ago, here is an update via the GC Bulletin:

Quote:
The helicopter was flying at 60m on Wednesday when it nearly collided with the drone. Picture: Westpac Lifesaver Rescue Helicopter Service.

Call from drone pilot training after near miss with Gold Coast chopper
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/70373654dd04500200fef506aea12bd0?t_product=GoldCoastBulletin&t_template=s3/chronicle-tg_tlc_storyheader/index&esi=true&td_noGallery=true&td_device=desktop[/img]Alison Marks, Gold Coast Bulletin
July 8, 2016 10:20am

It may be a case of.."damned if you do, damned if you don't"; however going off the track record of the Department & it's aviation safety agencies, I am somewhat suspect that Murky & his minions are obfuscating their responsibilities in a further attempt to limit the government's public liability on such issues as the rapidly growing plethora of small (<2kg) UAVs. That is they are once again divorcing themselves from the safety loop.

Today's Oz article by Binger does nothing to dispel my suspicions... :

Quote:Drone deregulation: fatalities will be a case of ‘when, not if’

Scott Goodkin cuts up a carrot with the spinning blades of a 2kg drone. Picture: Lyndon Mechielsen

• Mitchell Bingemann
  

Reporter
Sydney
@Mitch_Hell
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
Professional drone operators are putting pressure on the government to dump new laws that would deregulate the commercial operation of remotely piloted aircraft by the end of this month.

Peak group Australian Certified UAV Operators held a demonstration in Brisbane this week to underline its concerns about the rule changes, at which photographic drone pilot Scott Goodkin used the spinning blades of a drone to sever a raw carrot.

ACUO has enlisted the International Aerospace Law and Policy Group to help it put its case to government to fight the legislation, which will allow commercial operators to fly without a licence drones weighing less than 2kg from the end of this month.

The group thinks deregulating the operation of commercial drones will lead to an increase in civilian accidents.

“This amendment allows people to fly drones up to 2kg in weight, without any training, insurance, registration or certification. It will open Pandora’s box in terms of new dangers for airlines and the general public,” ACUO’s president Joe Urli said.

Operators must still obey standard flight rules, which are not to fly within 5.5km of an airport, above 400 feet or within 30m of buildings, railways or vehicles, and always to have line of sight of the drone.

The Civil Aviation Safety Authority requires that a list of these rules is included with the sale of any drone but ACUO says these are neither strict nor clear enough in explaining the risks.

IALPG principal Joseph Wheeler said the legislation was a step backwards for aviation regulation and that it would put Australia’s enviable aviation safety record in jeopardy.

“While the rest of the world are tightening restrictions on drone technology, Australia has put in place a level of deregulation which will end in a safety nightmare when, not if, the first fatalities ­happen,” Mr Wheeler told The Australian.

“Allowing the untrained, uncertified, uninsured and unproven to commercially offer services to the public for money, using high-powered, off-the-shelf (or homemade) drones, is reprehensible.”

A CASA spokeswoman said the amendments would cut costs and red tape for low-risk drone ­operations while continuing to prioritise safety.

“Requiring all commercial operators to be trained, qualified and certified to operate regardless of drone size would be an unnecessary regulatory burden on people carrying out low-risk RPA (remotely piloted aircraft) operations, including private model and recreational flyers,” she said.

Last year CASA issued 15 infringement notices for breaches of drone safety rules and has issued seven notices so far this year. Two investigations are under way.

Recent research by RMIT University showed technical problems were the cause of 64 per cent of drone-related accidents between 2006 and this year. The paper’s author said it would be necessary for stricter safety regulations to be put in place because Australian skies were used increasingly by commercial drone operators.

ACUO wants the regulations to revert to original rules to protect controlled airspace, aerodromes and airports from errant drones. It also wants all commercial operators to be properly trained, qualified and certified to operate, regardless of drone size.

 
MTF...P2  

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 11-02-2016

Here we go again -

Headline: Jetstar find a un-manifested elephant in A320 cargo hold

Background

Courtesy Aunty Pru (search 4 IP), Planetalking, ABC AM & ATSB...   

(08-23-2016, 07:48 PM)Peetwo Wrote:  

(05-14-2016, 10:49 AM)Peetwo Wrote:  Ben Sandilands getting up a head of steam -

Following on closely from the PT Cobham BAE-146 blog piece & the 50 odd comments that followed, Ben Sandilands has yet another 'serious' Jetstar incident to sink his teeth into to again highlight the appalling duplicity & selective bias by the inept, seemingly captured big "R" regulator CASA.

This ATSB investigation will also be interesting in that it could be regarded as the first real test for the soon to be Chief Commissioner Hoody to insure a totally non-PC'd final report is produced, warts & all.       

For background here is a rehash of the 'other' Jetstar incidents that were also covered by AP & PT...  

(12-05-2015, 09:51 AM)Peetwo Wrote:  AAI in a parallel universe - Will Aviation Safety again be the victim of Bureaucratic obfuscation & Political expediency..

Quote:Two serious Jetstar incidents under ATSB investigation

From the 'Closing the safety loop' thread & yesterday's ABC radio 'World Today' program:

Quote:WILL OCKENDEN: The Australian Transport Safety Bureau (ATSB) isn't the only one looking into this matter.

The aviation regulator, that's the Civil Aviation Safety Authority, or CASA has taken the unusual step of running its own investigation in parallel to the ATSB.

Peter Gibson is from CASA.

PETER GIBSON: We, of course, as the regulator, as the safety regulator need to look at immediate safety issues, be satisfied that they've been dealt with, that the causal factors have been understood by the airline and that the airline has taken the appropriate actions.

So that's why you've got two parallel investigations.

WILL OCKENDEN: What could be the outcome of a CASA investigation?

PETER GIBSON: Well, we're making sure most importantly that Jetstar is putting in place changes that will ensure these sorts of mistakes aren't made again.

Vivid memories of the last high profile 'parallel' investigation and we all know how that turned out -

Wonder if the operator will voluntarily ground all A320 operations until all the safety issues are effectively risk mitigated to the satisfaction of the regulator? - Yeah right & Elephants can fly  (see pic above)

[/url]  
Continued from ABC World Today program:

Quote:BEN SANDILANDS: These are really serious investigations.

WILL OCKENDEN: That's Ben Sandilands, an aviation writer and commentator for the crikey.com.au blog, Plane Talking.

He says the other incident, 10 days later on the 29th October, was far more serious.

BEN SANDILANDS: A Jetstar flight to Perth actually really struggled to take off from Melbourne airport at all. It was very nose heavy, clearly had gone too far down the runway to stop and that could have been a very serious incident.

WILL OCKENDEN: The Australian Transport Safety Bureau says it's investigating both incidents to find out how the so-called "aircraft loading event" occurred.

It's classified the incidents as "serious".

Ben Sandilands agrees.

BEN SANDILANDS: They moved people around on the flight so that they could land in the proper configuration in Perth. On the other incident, which was a Brisbane to Melbourne flight, they were out by more than, well, almost two tonnes in the weights and balances on the aircraft and so they had to adjust their landing calculations for Melbourne.

WILL OCKENDEN: They're supposed to do this before they take off. Is there any indication why those checks weren't done?

BEN SANDILANDS: None whatsoever. What is extraordinary and I've been talking to a number of pilots this morning who just cannot believe that something that is fundamental to a small tier country airline service could be messed up so badly by a scheduled airline.

It is beyond belief that an airline in Australia would push back and begin a flight without actually knowing how many people were really on board and indeed the other elements of the calculations as to where they were seated.

That's fundamental. That is the sort of stuff that airlines stopped making a mess of back in the 1950s and 1940s.

Ben Sandilands again with a follow up article:

Quote:[url=http://blogs.crikey.com.au/planetalking/2015/12/04/comment-why-action-should-be-taken-against-jetstar/]Comment: Why action should be taken against Jetstar

Ben Sandilands | Dec 04, 2015 5:48PM |

 
P2 comment: The mention of Nick Xenophon is extremely relevant because at a pivotal point in the Pilot training Senate Inquiry, when NX was zoning in on the dodgy safety culture of Jetstar (*1) - somewhat conveniently?? - CASA with very little warning took the bold step of grounding Tiger -

(*1 - Remember "Toughen up Princesses" & Ben Cook Darwin base Fatigue Special Audit report?)  

OK...so one more time round the Mulberry bush..  

&... TICK TOCK goes the Miniscule clock??

Ben S courtesy of Planetalking today:

Quote:Why Jetstar's latest incident should alarm flyers
The ATSB says a 'serious incident' is one that could end in a crash, and Jetstar has just had another one

Ben Sandilands
Jetstar’s tail strike incident at Melbourne Airport this week puts another red flag over the Qantas subsidiary’s operations and the unwillingness to date of the supposed safety regulator CASA to ground or restrict its flights.

However the ATSB appears to have fast tracked its inquiry into an incident that imperiled the lives of those on the 180 seat passenger jet bound for Hobart, indicating a final report will be provided by this November...

Update on ATSB Jetstar loading incidents investigation.

From the ATSB today:

Quote:Updated: 23 August 2016


Completion of the draft investigation report has been delayed due to competing team member priorities and workload, and to allow additional investigative work to be finalised.

This additional work includes:

• obtaining and consolidating additional evidence
  
• analysis of evidence held and the development and test of investigation findings.
  

When complete, the draft report will be released to directly involved parties (DIP) for comment and on the factual accuracy of the draft report. Feedback from those parties over the 28-day DIP period will be considered for inclusion in the final investigation report...

Yesterday:

Quote:Loading related event involving Airbus A320, VH-VQC, Sydney Airport, NSW, on 29 October 2016

 
Investigation number: AO-2016-145
Investigation status: Active
 

• Summary
  

Summary
The ATSB is investigating a loading related event involving a Jetstar Airbus A320, VH-VQC, at Sydney Airport, New South Wales, on 29 October 2016.

While unloading the aircraft, ground crew detected a baggage container in the cargo hold which had not been recorded on the loading manifest.

As part of the investigation, the ATSB will interview the flight and ground crew and gather additional information.

A report will be released within several months years -  
 
General details

Date: 29 Oct 2016
 
Investigation status: Active
 
Time: 15:25 ESuT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Sydney Airport
 
Occurrence type: Loading related
 
State: New South Wales
 
Occurrence class: Operational
  
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Feb 2017 
 
Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A320-232
 
Aircraft registration: VH-VQC
 
Serial number: 3668
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Gold Coast, Qld

Destination: Sydney, NSW
 
 
 


Last update 01 November 2016

- Wonder how long it will be before miniscule DDDD NFI Chester comes out swinging on behalf of Jet * saying that I'm merely scaring the travelling public - 

Quote:DARREN CHESTER:

No, I don’t think that at all, Fran. I think it’s quite irresponsible and inaccurate to be scaring the travelling public with unfounded claims about safety issues. Now…



MTF...P2  

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RE: Closing the safety loop - Coroners, ATSB & CASA - Gobbledock - 11-02-2016

Unbelievable that this mob are still allowed to fly. I started looking through the ATsB's incident data base and lost count of the amount of loading incidents, incorrectly positioned containers, damage to aircraft from ground equipment, unsecured containers.......it just doesn't end.

TICK TOCK indeed

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 12-05-2016

The Ghosts of Canley Vale revisited -  

(08-15-2015, 02:37 PM)Peetwo Wrote:  

(08-15-2015, 11:29 AM)crankybastards Wrote:  Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

Quote:K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.

I note off the UP that the tragedy & travesty of the unresolved, definitely obfuscated VH-PGW fatal accident at Canley Vale has once again resurfaced...

For the record :

Quote:Lumps

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

---

[url=http://www.pprune.org/members/133764-old-akro]Old Akro

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.

---

[url=http://www.pprune.org/members/41806-lead-balloon]Lead Balloon

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.

---

[url=http://www.pprune.org/members/331778-lumps]Lumps

Originally Posted by LeiYingLo 

Quote:Which is what any competent twin pilot knows to do and would've done in the first place

Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?

---

Old Akro

Quote:

Quote:Which is what any competent twin pilot knows to do and would've done in the first place.

The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.

---

[url=http://www.pprune.org/members/9979-adamastor]Adamastor

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.

---

[url=http://www.pprune.org/members/333707-thorn-bird]thorn bird

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

---

Adamastor

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Quote:

Quote:Is your assertion the pilot should have landed at YSRI?

No, it is not.

Quote:

Quote:There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

 
Agreed.

Quote:

Quote:I knew this young man very well, he was well trained…

I knew him too. It was a tragic loss, and yes, it is still raw.

Quote:

Quote:You arm chair experts are quick with your condemnation…

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Quote:

Quote:Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.

 
OK can anyone else see the common thread here? Here we have a perfect example of why it is important that we have a totally independent Annex 13 AAI that is free to investigate and establish the facts without external or internal ulterior motives for obfuscation and possible cover-up...


MTF...P2

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 12-20-2016

(12-05-2016, 09:34 PM)Peetwo Wrote:  The Ghosts of Canley Vale revisited -  

(08-15-2015, 02:37 PM)Peetwo Wrote:  

(08-15-2015, 11:29 AM)crankybastards Wrote:  Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

Quote:K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.

I note off the UP that the tragedy & travesty of the unresolved, definitely obfuscated VH-PGW fatal accident at Canley Vale has once again resurfaced...

For the record :

Quote:Lumps

Turbocharger failure and the incorrect engine shut down? Wouldn't be the first mishandled turbocharger failure in PA31s, and would explain a few things...

How come the ATSB were forced to revisit their wonky Whyalla report yet PGWs report is still in its original ignorant and incurious form?

---

Old Akro

The ATSB report was a crock. One of my favourite failings of the report was that they changed the radio transcript between the draft and final report. Another is that they used groundspeed (from radar returns) plus the forecast wind to estimate airspeed. But, they used made the same adjustment both flying away from Bankstown and returning to Bankstown. I forget the wind direction, but they (for example) gave it a headwind in both directions. Then they used this flawed arithmetic to criticise the pilots airspeed control!!

Its not at all clear that the pilot shut down the wrong engine. The engine he left operating was still operating, but failed to allow the aircraft to maintain altitude. It was never investigated whether the operating engine was capable of producing full power.

A factor that was never highlighted in the report is that the pilot complied with ATC descent requests. These descent requests were the standard profile that ATC use for its own convenience to descent IFR aircraft below the Sydney steps. So, the pilot did not find out that the aircraft would not maintain altitude until it was too late and his fate was sealed. For me a massive lesson is that ATC are not necessarily going to have your best interests at heart in an emergency. If the pilot had refused to comply with the ATC descent requests and maintained altitude, there would have been a happier outcome.

---

[url]
Lead Balloon

I'm appalled to note that I'm unsurprised to note another ATSB 'report' that is a mixture of fiction and inept bungling.

[/url]

---

[url][url]
Lumps

Originally Posted by LeiYingLo 
[/url][/url]

Quote:Which is what any competent twin pilot knows to do and would've done in the first place

[url][url][url]

Simplistic answer that doesn't help.

Akro et al, Furious agreement gents, but I didn't mean to revive this thread for repetition.

Even with the ATC descents it should have maintained height at 2500ft on one... unless the one that was going was only putting out a bit over 200hp in its naturally aspirated form

- in the tests following the accident was the scenario and performance of one engine shut down and one operating without turbocharger evaluated?

- with this in mind was the turbocharging system on the 'good' or operating engine really closely examined? Or was it assumed that the bad engine was the one that the pilot shut down, and this was the one that got most attention? (perhaps the ATSB investigators are time poor and are under some form of pressure to get results under time constraints, leading to unconscious bias or assumptions that suit their own situation, so to speak)

- maybe it all was done by ATSB, but in reports of yesteryear a hypothesis would be proposed and the proven or disproven with the available evidence (or insufficient evidence, which no doubt is what happened here, but at least mention that in its relation to the hypothesis!)

- for those of us that want to know, I'd argue all of us that have lives invested in aviation, what is the avenue to get reports re-examined?

[/url][/url][/url]

---

[url][url][url]
Old Akro

Quote:
[/url][/url][/url]

Quote:Which is what any competent twin pilot knows to do and would've done in the first place.

[url][url][url]

The pilot was young. He was under great stress. He received what was essentially was an instruction from ATC. He needed to descend anyway. I don't condemn him for complying or blindly trusting that the instruction was in his best interests rather than traffic management expediency.

The issue is that the ATSB have a massive blind spot about this and other issues which firstly, denies the ability to understand the truth of the situation and secondly to learn from the experience.

It was a scandalously shabby report.
[/url][/url][/url]

---

[url][url][url]
Adamastor

The first transmission from ATC to the pilot was maintain 5000’ which the pilot accepted but then either chose not, or was unable, to do. They descended below that assigned level and were then issued further descent.

ATC then specifically asked the pilot whether they were capable of maintaining altitude and advised that if they were unable, that YSRI aerodrome was 2nm away. They got another non-committal response, the aircraft overflew YSRI, and the rest is tragic history.

Your assertion that a controller would deliberately put an IFER (in-flight emergency response) aircraft in increased danger because it suited their airspace layout or traffic management is disgusting.

[/url][/url][/url]

---

[url][url][url][url]
thorn bird

Adamaster,
is your assertion the pilot should have landed at YSRI? I passed over RIC shortly after the event. The runway was obscured by Fog.

There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

I have experienced an engine failure in the type aircraft and had no problem maintaining height for a considerable distance, over 60 NM.

Listen to the voice of the young pilot on the tapes, he is cool, calm, in control and endeavouring to find solutions to his problem, he flew his aircraft under control to the very end.

I knew this young man very well, he was well trained and very well aware of the limitations of the aircraft he was flying.

You arm chair experts are quick with your condemnation, but you were not there on the day, nor is there anyway to establish what actually occurred.

Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

[/url][/url][/url][/url]

---

[url][url][url][url][url]
Adamastor

Thorn_bird, I can see that this was a difficult accident to deal with for both of us.

Quote:
[/url][/url][/url][/url][/url]

Quote:Is your assertion the pilot should have landed at YSRI?

[url][url][url][url][url]

No, it is not.

Quote:
[/url][/url][/url][/url][/url]

Quote:There is nothing in the ATSB report about organisational, operational and bullying issues with the operators chief pilot, reported to CASA but ignored.

[url][url][url][url][url]
 
Agreed.

Quote:
[/url][/url][/url][/url][/url]

Quote:I knew this young man very well, he was well trained…

[url][url][url][url][url]

I knew him too. It was a tragic loss, and yes, it is still raw.

Quote:
[/url][/url][/url][/url][/url]

Quote:You arm chair experts are quick with your condemnation…

[url][url][url][url][url]

The only person I was attempting to ‘condemn’ was Old Akro for stating that the ATC deliberately placed a stricken aircraft in further harm’s way for something as trivial as airspace layout or ‘traffic management expediency’. Attempting to lay blame after a tragedy is a natural response, but that was uncalled for and simply not true.

Quote:
[/url][/url][/url][/url][/url]

Quote:Suffice it to say, any SAFETY issues that may have been learnt went out the window to protect a vindictive incompetent regulator.

[url][url][url][url][url]

I learnt plenty from this one (and would gladly give it all back in a heartbeat), but I agree that other valuable lessons were lost in the haze. Safe flying.[/url][/url][/url][/url][/url]

http://[url][url][url][/url][/url][/url]

http://[url][url][url][/url][/url][/url]

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-18-2017

(03-17-2017, 08:55 AM)Peetwo Wrote:  Update 17/03/17: Widow condemns CASA as 'incompetent' & 'dysfunctional' -

Reference posts:

(03-13-2017, 07:47 PM)Peetwo Wrote:  

(03-13-2017, 05:34 PM)Peetwo Wrote:  Next I note that NSW Deputy Coroner today handed down his findings on the tragic 2013 Dromader fire fighting accident near Ulladulla. From AAP via the Oz:

Quote:Pilot died after 'inadequate' inspection

• Jodie Stephens
  
• Australian Associated Press
  
• 4:32PM March 13, 2017
  

A waterbombing pilot fighting a NSW blaze was killed after his plane's wing broke off mid-flight as a result of cracking and corrosion that was missed during an "inadequate" inspection months earlier, an inquest has found.

David Black, 43, died when his M18 Dromader aircraft crashed in an isolated and mountainous area of the Budawang National Park, in the state's south, on October 24, 2013.

The experienced pilot was preparing to attack a bushfire when the left wing of his aircraft suddenly broke off, causing the aircraft's rapid descent, Deputy State Coroner Derek Lee wrote in his inquest findings released on Monday.

Mr Black left behind his wife of 12 years, Julie, and three young children.

"David and Julie had worked together as a team, industriously, to reach a stage in life where their business was successful, their family was nurtured and cared for, and they were simply able to enjoy life," Mr Lee wrote.

"To lose David in sudden circumstances is heart-rending."

The plane Mr Black was flying was owned by his company, Rebel Ag, which provided aerial support to the NSW Rural Fire Service.

It was tested and inspected just over two months earlier by two companies, Aviation NDT and Beal Aircraft Maintenance, but Mr Lee said the work was inadequately done.

He wrote in his findings that testing by Aviation NDT used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority.

Further, the plane's wings were not removed during a visual inspection by Beal Aircraft Maintenance, meaning that corrosion and cracking on one of the left wing's attachment lugs was not detected.

By the time Mr Black crashed in October, the Australian Transport Safety Bureau found that cracking on the inner surface of the lug had reached a critical length of 10.4 millimetres and at least 32 secondary micro cracks were also identified.

The engineer behind the visual inspection, Donald Beal, told the inquest the manufacturer's service bulletin did not mandate removal of the wings, so he didn't see any need to remove them.

Mr Beal also said there was ambiguity about what visual inspections actually involved, Mr Lee recalled in his findings.

At the NSW Coroner's Court on Monday, Mr Lee recommended that CASA consider issuing a directive that wings be removed during inspections of M18 Dromader planes.

He also recommended they consider a different way of calculating fatigue damage, which did not just rely on flight hours but also looked at other factors that age an aircraft, such as its speed and the weight of loads that it carries.

A CASA spokesman said they would consider the recommendations carefully.

Update to NSW Deputy Coroner report.

Quote:Firefighting plane that crashed killing pilot had maintenance issues, inquest finds
ABC Online
 - ‎1 hour ago‎

The Sydney court heard Mr Black's plane was inspected on the 8th of August, 2013, using an alternative, less sensitive procedure that was not approved by the Civil Aviation Safety Authority (CASA). In his report, the Coroner asked: "Was the August 2013 ...

---

Safety inspection failed to detect fatal corosion in plane's wing
dailytelegraph.com.au
 - ‎5 hours ago‎

State Coroner Derek Lee found on Monday that an inspection of the plane conducted 11 weeks prior to the crash used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority. Cracking and corrosion ...

Courtesy the Oz today:

Quote:Solo mum keeps business afloat

Julie Black has been flying solo for the past 3½ years in more ways than one.

Quote:..After the accident, Ms Black had to replace the Dromaders with Air Tractors, and find a chief pilot, as well as juggling the raising of her children. “The business is still going. It is still employing people and maintaining services to our clients,” she says.

Ms Black vowed to never put pilots in Dromaders again and has since bought four Air Tractors for spraying.

“It has been extremely hard when you are used to working with someone in a partnership for 17 years, and been able to tag-team between work life and home life,’’ she says.

“When you have lost that 50 per cent and you are now 100 per cent on your own … all our decision making was done ­together.

“Now I lie in bed and night and wonder if I have made the right ­decision and what would David have thought about whatever the issue is at hand.’’

‘Incompetent’ CASA slammed

Quote:...Ms Black said the inquest by the deputy State Coroner Derek Lee showed the crash involving a Polish-built M18 Dromader was a textbook example of the Swiss cheese theory of accidents. This theory postulates that holes develop because of human error and dysfunction, and eventually they link up to cause serious accidents.

“In this accident when you go back and you look at all the holes that were lining up over a matter of 13 years, this aircraft was doomed. Had we known that we obviously would never have flown it,” Ms Black said. “When you go back through the ATSB report you can see the holes developing right back to 2000. In just about every single one of those holes CASA is involved. How CASA originally said you could use a flawed testing system (the eddy current technique) is unbelievable. It was contrary to what both the manufacturer and the FAA had mandated as the correct testing method.”

Ms Black’s solicitor, Mark Gray-Spencer of GSG Legal, said the evidence presented to the inquest clearly showed CASA failed to identify the fact that the maintenance company, Beal Aircraft Maintenance, and its non-­destructive testing company, Aviation NDT Services, was using the wrong method to test the attachments on the Dromader wings.

“Aviation NDT used an eddy current technique to test the wing attachments which was contrary to what both the manufacturer and the FAA said should be used. Both had advised that Magnetic Particle Testing had to be used,” Mr Gray-Spencer said.
“Six weeks after the approval from CASA for the eddy current technique was sent to Neil Joiner (of Aviation NDT Services), CASA issued an airworthiness directive (AD) stating that you had to use magnetic particle testing. This was inconsistent with the eddy current technique approval. The maintenance organisation should have looked at the AD and realised their procedure was not OK.”

An AD is a legislative instrument issued under federal law.

“For 13 years, from the issuing of the AD until the accident, the wrong testing was used,” he said...

And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
   
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  -  

P2 comment: Gutsy lady Ms Black! - Welcome to the ranks of the IOS...


MTF...P2

Ps "K" this may have to be moved to the 'Closing the safety loop' thread...

(03-18-2017, 06:41 AM)kharon Wrote:  A complimentary round trip ticket.

P2 – “And here is Pinocchio Gobson with the totally predictable zero care, zero responsibility, "we're looking into it" bollocks statement:
 
“CASA has been looking carefully at the Coroner’s report and recommendations. There are a range of issues to be considered and CASA is working through these methodically. We appreciate issues raised by the family are important.”

- That is word-weasel bureaucratese for.. "this will be O&O'd till we can quietly shuffle the report in to the infamous CASA shelf-ware out-tray"  -  

P2 comment: Gutsy lady Ms Black! - Welcome to the ranks of the IOS...

Welcome indeed. One of the reasons people can sit at home watching horrific stories of carnage, destruction, tragedy, fire or even aircraft accidents on the TV while eating their dinner is that it ain’t ‘personal’. Nowadays, folk rush off to ‘counselling’ after they’ve had a splinter removed from their arse and tell everyone who will listen about the trauma and how they intend the sue the council because the park bench surface was not ‘safe’. Why? Well it’s now ‘personal’. It’s the same with ‘CASA contact’; until the filthy spectre has tapped you on the shoulder; it ain’t personal. But when it does……Problem is that from the minister down, no one, except those affected ‘get it’. The vast majority of aircrew and engineers have never had the dubious pleasure of dealing with CASA other than in the routine way of medicals and such. DAME’s, Chief pilots, etc. all have had ‘the experience’ even then that’s a mixed bag: and, the 'go along to get along' syndrome has resulted in some truly awful aberrations; I digress. See Thorny’s post – HERE – for just a small part of the problem.  

P2 - “Ps "K" this may have to be moved to the 'Closing the safety loop' thread...

It probably should be mate; but you know as well as I the CASA response to coronial recommendations; they are treated as opinion. What did we examine when we did the analysis; some thirty or so cases? We selected just a few to provide a range and for all the good that hard work has done, we could have stayed in the pub; (practiced your darts).

HITCH - (Oz Flying)– “Only by the reaction to these truths can we judge the commitment of the Federal Government. However, we need to lift our chins and plod on; we have more hope of reform with the advisory group than we would have without them.”

Hitch and probably the GAAG understand the truth of it; but, what else can they do? The ‘CASA’ experts who have royally buggered the system and wasted hundreds of millions while getting paid handsomely to do so now expect ‘help’ from industry experts, who are not only doing it all ‘for love’ but taking time, resource and energy away from their own interests. Do they have to cooperate? Well I suppose they do; but its not the first time and it most certainly will not be the last time an industry advisory panel has laboured – in vain. History children, history. Not too far back – Pel_Air?, Forsyth? Ring any bells?

FWIW, I reckon the minister and CASA are taking the Mickey – again; same old tune, same old result. One may fervently hope for the best but it always most sensible to expect and prepare for the worst.

We wish Mrs Black well and any small support we can offer. The first part of this story is tragic and life changing; the second part is in the lap of the gods. Personally, I would not abandon all hope just yet, but I wouldn’t be holding my breath either.

Toot toot.

---