The search for investigative probity. - Printable Version

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

Popinjay and Hoody taking the piss on ICAO Annex 13 final report compliance??

Via the Dicky King thread:

(12-01-2023, 06:32 PM)Peetwo Wrote:  

Chalk & Cheese: S is for? - Surveillance.

As a clear chalk and cheese comparison, I refer to another ATSB systemic investigation - AO-2018-078. In regards to CASA oversight, the following is the overview summary (page 29):

Quote:The Civil Aviation Safety Authority (CASA) had two primary means of oversighting a specific operator’s aviation activities: regulatory services and conducting surveillance of its activities. They also used a scale of prioritisation, based on risk, to determine where to focus resources. This prioritisation was based on several factors, such as the sector of operation, organisational changes and challenges.

To maintain oversight across Australian operators (authorisation holders), CASA had a number of certificate management teams in different locations, made up of CASA officers, including flying operations inspectors, safety systems inspectors, and airworthiness inspectors. Each of these teams oversighted multiple authorisation holders. At the time of the accident, the team responsible for the oversight of Airlines of Tasmania comprised of one certificate team manager, three flying operations inspectors, four airworthiness inspectors and one safety system inspector. The team had oversight of 58 AOC holders, 50 aviation maintenance organisations and four delegates.

This oversight summary is strangely remiss in the AO-2022-009 report, despite (I would have thought) being equally applicable??

In the meantime from the BRB, here is the 'King Aviation Swiss Cheese' model for the Miniscule to refer...

In reference to the 'Previous investigations with surveillance and hazard identification findings', listed in the  AO-2018-078 investigation, I checked for the applicable section for 'CASA Oversight': 

AO-2017-057: 

 

Quote:Regulatory oversight

Overview

The stated mission of the Civil Aviation Safety Authority (CASA) is ‘To promote a positive and collaborative safety culture through a fair, effective and efficient aviation safety regulatory system, supporting our aviation community.’

CASA was responsible, under Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia, including by:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

CASA had documented a regulatory philosophy that included maintaining a risk-based approach to decision making, and being consultative and collaborative with industry, while balancing consistency with flexibility in its work.

CASA had two primary means of oversighting a specific operator’s aviation activities:

• regulatory services, by assessing applications for the issue or variations to its AOC and associated approvals (including approvals of key personnel)
  
• conducting surveillance of its activities.
  

CASA used a scale of prioritisation based on risk to determine where to focus resources. This prioritisation was based on a number of factors, such as the sector of operation, organisational changes and challenges.

In order to maintain oversight across Australian operators, CASA had a number of certificate management teams (CMTs), made up of CASA officers, including flying operations inspectors (FOIs) and airworthiness inspectors (AWIs), in different regions of Australia. Each of these teams oversighted a number of AOC holders. The majority of the oversight of Rossair was conducted by an Adelaide-based team.

AO-2017-005:

Quote:Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section 9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;

(d) developing effective enforcement strategies to secure compliance with aviation safety standards…

(e) issuing certificates, licences, registrations and permits;

(f) conducting comprehensive aviation industry surveillance, including assessment of safety‑related decisions taken by industry management at all levels for their impact on aviation safety…

The two primary means of oversighting a specific operator’s aviation activities were:

• assessing applications for the issue of or variations to its AOC and associated approvals (including approvals of key personnel)
  
• conducting surveillance of its activities.
  

AO-2009-072:

Quote:Regulatory oversight

The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act 1988, for the
safety regulation of civil aviation in Australia and of Australian aircraft outside of Australia. Section
9(1) stated the means of conducting the regulation included:

© developing and promulgating appropriate, clear and concise aviation safety standards;
(d) developing effective enforcement strategies to secure compliance with aviation safety standards;
(da) administering Part IV (about drug and alcohol management plans and testing);
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance, including assessment of safety‐related
decisions taken by industry management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in order to monitor the safety
performance of the aviation industry, to identify safety‐related trends and risk factors and to promote
the development and improvement of the system;
(h) conducting regular and timely assessment of international safety developments.

The two primary means of oversighting a specific operator’s aviation activities were:

 assessing applications for the issue of or variations to its AOC and associated approvals
(including key personnel and the training and checking organisation)
 conducting surveillance of its activities on a regular basis.

Up until 2004, CASA oversight of the operator’s jet AOC was conducted by the Bankstown
general aviation (GA) field office276 and oversight for the operator’s turboprop operation was
conducted by the Brisbane air transport office. In August 2004, responsibility for oversighting the
turboprop AOC was transferred to the Bankstown office. The Bankstown office retained oversight
responsibility for the operator when the two AOCs were merged in October 2006.

This section briefly overviews the processes involved in assessing variations and conducting
surveillance, and then discusses CASA’s oversight of specific aspects of the operator’s activities.
The section focusses on CASA’s oversight of flight operations activities conducted under the
operator’s AOC during 2005–2009, with some events prior to 2005 discussed when relevant.

Curious to how far back this standard format for the 'CASA Oversight' summary in ATSB systemic operator investigations, I went to the biggest CFIT investigation in this century IE 'Collision with Terrain - Fairchild Metro 23 aircraft, VH-TFU 11km NW Lockhart River Aerodrome, Qld 7 May 2005'

Quote:1.18 Regulatory oversight of Transair and Aero-Tropics

1.18.1 The function of the Civil Aviation Safety Authority

CASA was responsible, under the provisions of Section 9 of the Civil Aviation Act
1988, for the regulation of aviation safety in Australia. Section 9 of the Act
included the following:

(1) CASA has the function of conducting the safety regulation of the
following, in accordance with this Act and the regulations:

(a) civil air operations in Australian territory;
(b) the operation of Australian aircraft outside Australian territory;
by means that include the following:
© developing and promulgating appropriate, clear and concise
aviation safety standards;
(d) developing effective enforcement strategies to secure compliance
with aviation safety standards;
(e) issuing certificates, licences, registrations and permits;
(f) conducting comprehensive aviation industry surveillance,
including assessment of safety-related decisions taken by industry
management at all levels for their impact on aviation safety;
(g) conducting regular reviews of the system of civil aviation safety in
order to monitor the safety performance of the aviation industry, to
identify safety — related trends and risk factors and to promote the
development and improvement of the system;
(h) conducting regular and timely assessment of international safety
developments.

The two primary means of oversighting an operator’s aviation activities were
assessing applications for the issue of or variations to its Air Operator’s Certificate
(AOC) and associated approvals (including key personnel and training and
checking organisation), and conducting surveillance of its activities on a regular
basis.

The only exceptions to this standard format that I have been able to find so far are Croc-o-shite and the VARA ATR broken tail accident reports:

Quote:Anyone else see the ironies of the examples that the ATSB has picked on?? Wonder why they didn't include the VARA ATR-72 broken tail accident?? Oh that's right they farmed that part of the investigation off to a 'Case study: implementation and oversight of an airline's safety management system during rapid expansion':  Update: ATSB PC accident investigation AO-2014-032

Quote:Overview of the investigation

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

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

As part of its investigation, the ATSB:

interviewed current and former staff members of the operator, regulator and other associated bodies
examined reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
reviewed other investigations and references where similar themes have been explored.

This stitched up Hooded Canary investigation waffled along aimlessly for 3 years until it was subsequently discontinued: 

Quote:Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

"...The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations..." - Unless of course you're the 'Croc Wrangler'??? - 

Before we move on from the Hooded Canary's successful cover-up of the flawed CASA oversight of the VARA ATR operation, remember this? Ref:  Update: ATSB PC accident investigation AO-2014-032 

 

It is interesting to note that in the rather lengthy 1st interim report, the following was stated:

Quote:Investigation activities to date
To date, the ATSB has collected information about, and analysed the following:

• the sequence of events before and after the pitch disconnect, including the post-occurrence maintenance and initial investigation by Virgin Australia Regional Airlines (VARA) and ATR
  
• flight and cabin crew training, qualifications, and experience
  
• the meteorological conditions
  
• VARA policy and procedures
  
• VARA training courses
  
• VARA’s safety management system
  
• VARA’s maintenance program
  
• the aircraft’s systems
  
• the relationship between VARA and the maintenance organisation
  
• maintenance engineer training, qualifications, and experience
  
• the maintenance organisation’s policy and procedures
  
• the maintenance organisation’s training courses
  
• the maintenance organisation’s quality and safety management
  
• the Civil Aviation Safety Authority’s (CASA) surveillance of VARA
  
• CASA’s approvals granted to VARA
  
• CASA’s surveillance of the maintenance organisation
  
• CASA’s approvals granted to the maintenance organisation
  
• ATR’s flight crew type training
  
• ATR’s maintenance engineer type training
  
• ATR’s maintenance instructions for continuing airworthiness
  
• known worldwide in-flight pitch disconnect occurrences involving ATR 42/72 aircraft.
  

So the CASA Oversight had been completed and apparently analysed, yet the findings and analysis were not included in the final report...

Back to the 'Croc-o-shite' report and the bizarre omission of the 'CASA Oversight' standard format. The following is a very alarming Oz article (TY CW -   ) from 14 July this year:

Quote:Accusations of safety breaches show failure to rein in Outback Wrangler Matt Wright



The Civil Aviation Safety Authority had investigated scores of incidents involving celebrity croc-wrangler Matt Wright and his company Helibrook in the decade preceding the fatal chopper crash that killed Netflix star Chris Wilson.

The Australian has obtained, under Freedom of Information laws, CASA documents which – despite being heavily redacted – reveal the regulator has been aware of suspected safety breaches involving Helibrook for about 12 years.

Wright burst onto CASA’s radar after the first series of his reality television show Outback Wrangler hit screens in 2011.

When those first four episodes – produced for National Geographic and bankrolled by Screen NSW – were broadcast, a member of the Northern Territory Government’s crocodile management program contacted CASA and “raised concerns” about Wright’s “aviation operations”.

After reviewing the footage, investigators alleged Wright and his co-star Michael Burbidge had possibly committed up to 14 safety breaches, during a six-week period, while filming in late 2010.

That assessment was based solely on what CASA could see in the final cuts.



The possible offences – involving five different choppers – included reckless operation of an aircraft, low flying, carrying firearms, carrying live animals, not wearing seatbelts, not restraining cargo, unapproved modifications and conducting commercial operations without an air operator‘s certificate.

But before the ink was dry on CASA’s report Wright was back in the spotlight after the NT News published a front-page photo of what was alleged to be someone shooting a crocodile from a helicopter he was flying.

CASA did not investigate the April 2013 incident but NT Parks and Wildlife did.

A witness alleged that shots were fired from the helicopter as it hovered over the mouth of Shady Camp, 110km southeast of Darwin, which is known for its high concentration of crocodiles.

‘‘(I) spotted these guys about a kilometre away shooting a croc outside the river mouth, winching it up and flying to shore and land,” he told the newspaper.

But Wright, who said he was taking a client heli-fishing and on an adventure tour, denied they had shot towards the water, adding that there might have been a few gunshots heard earlier when they were shooting pigs over land.

‘‘We were just flying over looking at all the boats on the water,’’ he said.



‘‘We saw a barra caught in the shallows and he (the client) jumped out and grabbed it, and we flew to the bank to secure it.’’

The client, David Blanck, refused to comment on the gunshots but said he had jumped out to grab the fish.

‘‘We saw a barra and I asked Matt what he thought, and he said ‘jump in and get it’, and that is pretty much what we tried to do,’’ he said.

‘‘I jumped down, got it and tied it to the skid with a bungee cord, and flew to the bank and took photos.”

The Parks and Wildlife Commission investigated but cleared the men of any wrongdoing after seeing a picture of a barramundi they had caught.



When the story was published, Wright was angry and Burbidge, who owned the chopper, allegedly stormed into the NT News building and had a go at the paper’s editor.

A year later, in a separate alleged shooting incident, the owner of a fishing charter business reported seeing two R44 helicopters flying low, near the mouth of the Finniss River, while those on-board discharged what appeared to be automatic firearms. The man alleged to police that one of the pilots was Wright.

He said the choppers were hovering and circling around as if looking for something, possibly pigs, and firing volleys of shots in quick succession.

He further claims that bullets were landing within 100m of him and others who were fishing in the area, causing them to fear for their lives.

When the fisherman called triple-zero the operator said that she also could hear the shots being fired.

“He could hear the whizzing of bullets and they ducked their heads into the boat,” CASA recorded.

Police contacted Wright to arrange an interview but his travel schedule made it hard.

When CASA contacted him, he said the complaint was “untrue”, “didn‘t happen” and that he “had no knowledge of this incident”.

Wright said his log book was not up to date and he couldn’t remember his movements that day but if he was in the area, he would have been 10 nautical miles back from the Finniss River and that the fisherman “complains about that sort of thing all the time”.

“As soon as he sees helicopters and hears shots he brings him (Wright) into it,” the investigator recorded Wright as saying.

“It is bullshit and he is sick of it.

“This is not helping his AOC application and he does not need this.”

CASA decided there was insufficient evidence of wrongdoing.

In the midst of these accusations the rising star was having a blast with his Hollywood actor mate Gerard Butler who was Down Under filming Gods of Egypt.

In March 2014 Wright took the star of 300 on a bespoke outback adventure that involved buffalo hunting, heli-fishing and airboat rides.

When Butler returned to the US, he giddily shared a home video of Wright’s wild chopper flying during an appearance on Jimmy Kimmel Live.

The 20-second clip shows Wright’s black Robinson R44 hurtling towards Butler and others, before aiming its rotor towards the men and spinning above their heads for a terrifying few seconds before landing a few metres away on the beach.

“This guy is quite a famous adventurer in Australia,” the Scottish actor told Kimmel.

“I don’t want to say his name because it was … There was a lot of stuff I couldn’t even put on this video by the way. This is the tame stuff.”

As the footage began to roll, Butler told the host “this is how we were flying about”.

“We didn’t even upload the best bit of this where we were spinning around at 70 miles per hour and him in the chopper right above us,” he said.

Sources close to the incident say that when the footage, filmed at the Peron Islands, was made public, Wright was “wild” that Butler had shared the private clip.

Experienced helicopter pilots have told The Australian that the chopper’s perceived proximity to the people on the beach appeared to breach CASA regulations and that for several seconds the chopper was within “the dead man’s curve”.

“Any cough or splutter from the engine would’ve killed them all,” a source said.

But after reviewing the footage and interviewing Wright, CASA found no breaches had occurred.



In any case, by the time CASA became aware of Butler’s video, investigators had their hands full with another alleged incident involving that same chopper, registered VH-MEB, after receiving a tip-off that it had drowned.

“Yes that is correct that MEB did go underwater the other day when I was on my way back to the shack,” Wright emailed a CASA investigator in June 2014.

“Wasn‘t a good weekend that one as I also had a major on the airboat about three days earlier.

“But with MEB I had landed on the beach to have a quick flick before starting work that afternoon.”

Wright said that when he went to start the chopper again, there was “no power”.

“It was a diode of the starter relay that had stopped working so by the time the engineer got there it was too late with the incoming tide and water was lapping up around the belly and we could not get it started at that stage.

“I know this isn‘t going to help my current investigation but there wasn’t much I could do to prevent this one Pete and I’ve lost my machine that I still have to pay (Mick Burns) out for it as the insurance didn’t cover the total cost, so this one has hurt a bit.”



Wright told CASA that he was alone when it happened and that the helicopter’s Maintenance Release – where flying time is recorded – had floated away.

Burbidge flew out to retrieve the wreckage via sling load beneath his Squirrel.

Days later Wright sold the written-off chopper to his mentor, cattle baron and former reality television star Milton Jones, who later changed its registration to VH-NTH.

A year before MEB went underwater, Wright had slung a 23-year-old man with cancer – Jett Brewster – beneath it “for some sightseeing”.

CASA was alerted when the November 2013 edition of North Australian Fishing and Outdoors magazine published a story about it with photos.

The article, written by his Outback Wrangler co-star Wilson, said that “Jett dangled airborne below the chopper for more than 30 minutes as Matt flew across some of the vast landscapes of the Top End”.

When CASA interviewed Wright and Brewster, who passed away last month, both said the slinging had only been for five minutes along the shoreline and Wright said he didn’t think he needed authorisation because it was a “private operation”.

“He had done it because Jett wanted to experience what he (Wright) did for work,” the CASA investigator recorded of his conversation with Wright.

“He (Wright) thought ‘why not as Jett did not have long to live’.”

In August 2015 CASA asked Wright to show cause why it should not – in light of previous incidents including the Butler video – vary, suspend or cancel his Air Transport Pilot Licence or Commercial Pilot Licence.

In March 2016, CASA decided – after considering Wright’s response and representations made on his behalf – not to vary, cancel or suspend his licenses.

“Rather, in this instance, I have decided to counsel you,” the acting regional manager wrote in a 10-page Notice of Counselling letter.

Only two pages of this letter were not redacted before it was released to The Australian.



“Therefore the purpose of this letter is to formally record that you have been counselled during our face-to-face meeting in the Darwin CASA office on 9 March 2016,” it concluded.



But Wright’s aviation issues were far from over.

In April 2017, a helicopter sub-hired from Wright’s mate and former business partner Troy Thomas crashed in Western Australia, injuring passengers and sparking CASA and Australian Transport Safety Bureau investigations.

The Robinson R44, registered VH-SCM, crashed into the water after taking off for a charter flight from the top of a boat at Talbot Bay.

Thomas’s company Horizontal Falls Seaplane Adventures owned the chopper but was operating under Wright’s AOC.

The pilot and two passengers, who suffered minor injuries, had to exit the helicopter underwater and swim 50m to shore before being treated at hospital.

Then in August 2017, pilot Jock Purcell crashed one of Helibrook’s Robinson R44s, registered VH-LGN, in the NT with three passengers on board.

In December that year, CASA called Wright again after the newlywed regaled the Herald Sun with a story, about how he had told his wife Kaia to jump from a hovering helicopter to chase a pig, which was then printed in an article about their outback romance.

In 2018, CASA launched a noncompliance investigation into Helibrook after receiving complaints about five alleged incidents of “unsafe behaviour” in helicopters associated with Broome-based Horizontal Falls Seaplane Adventures, which was still operating under Wright’s AOC.

The complaints to CASA included reports and videos of “deliberate and systematic low-flying and vessel-harassment”, unsafe behaviour by a helicopter in relation to a seaplane, an illegal landing on Cockatoo Island and reports of a helicopter departing Broome in thick fog.

“This organisation is conducting itself in a manner which demonstrates a systemic and belligerent disregard of legal and safety obligations over an extended period,” one complaint alleged.

A pilot, with “several thousand hours of experience” told CASA he was “aghast” when he saw a helicopter take off from Broome with “zero visibility”.

“Other pilots were watching and shaking their heads,” he wrote. “I have photographs of this morning that proves the conditions were nowhere near legal.”

WA National Parks and Wildlife had also ordered one of the pilots to attend mediation with them.

CASA said the activity in the videos “depicted helicopters engaging in manoeuvres which placed the aircraft in situations of varying risk profiles” but ultimately concluded that the complaints could not be substantiated.

In late 2018, Wright turned up at Airwork Helicopters in Caboolture, north of Brisbane, where he reportedly told students that “CASA had sent him back to flight school”.



In May 2019 CASA sent Wright a “notice of decision to vary commercial pilot licence”.

A couple of months later, CASA sent him a “notice of decision to vary conditions on commercial pilot licence”.

Both letters were fully redacted before being released to The Australian.



At the turn of the decade, in 2020, Helibrook’s affairs took a turn for the worse, after a seemingly benign incident involving an R44 with the registration VH-XHB.

In August 2020, Helibrook reported to CASA and the ATSB that “while repositioning for refuel, the helicopter landed hard” at Wright’s Top End Safari Camp and that the pilot was the only person on board.

“The pilot was not injured and the helicopter sustained moderate damage to the undercarriage,” a CASA report from September 2020 states.

As a consequence, CASA deemed that “no further CASA action is recommended with respect to the company” and did not investigate further.

Nothing more would have come of it if it had not been for Wilson’s fatal crash two years later.

On February 28 last year, Wilson was killed when Helibrook’s VH-IDW, which he was slinging beneath, crashed during a crocodile egg collecting mission at West Arnhem Land. Pilot Sebastian Robinson was critically injured and is still recovering from severe spinal injuries.
During their investigation NT Police publicly appealed for anyone who had flown on board the destroyed chopper, which was also used for charter flights, to submit their photos and footage.



Lo and behold tourists who had been on VH-XHB when it crashed in 2020 also came forward and reported that an alarm sounded before the chopper fell about 10 metres and made a hard landing.

At the time Wright, who was not the pilot, was informed one of the tourists had recorded a video of the incident.

It will be alleged that after viewing the footage, Wright asked the tourist not to share it with anyone, before providing the passengers involved in the incident with free alcohol and refreshments.

Since Wilson’s death, which is still under intense scrutiny, CASA has launched another five investigations into Helibrook.

Of those, one is about the fatal crash and another relates to alleged “unsafe behaviour reports”.

Helibrook’s operations were voluntarily suspended last year but Wright, who still has his pilot licence, is still flying.

CASA said it was inappropriate to comment “noting other ongoing matters under investigation”.

Wright declined to comment.

If you believe it is remotely possible that the ATSB was not aware of any of these disturbing tales of regulatory safety breaches involving both the Matt Wright and Troy Thomas commercial, airwork and private operations - I've got a lovely bridge in Sydney Harbour going cheap...  

Why go to such lengths to cover up the CASA negligence to properly oversight the Matt Wright and Troy Thomas cowboy outfits?

The following is one BRB hypothesis doing the rounds. Under ICAO Annex 13, APPENDIX I - FORMAT OF THE REPORT, para 1.17 it states:

Quote:1.17 Organizational and management information.

Pertinent information concerning the organizations and their management involved in influencing the operation of the aircraft. The organizations include, for example, the operator. the air traffic services, airway. aerodrome and weather service agencies: and the regulatory authority. The information could include, but not be limited to, organizational structure and functions, resources, economic status, management policies and practices. and regulatory framework.

It then says under 'Analysis':

Quote:2. ANALYSIS

Analyse, as appropriate, only the information documented in I. - Factual information and which is relevant to the determination of conclusions and causes.

From a legal perspective, by the ATSB leaving out 'CASA Oversight' in the context section, means that there is no need to properly analyse the obvious complete lack of surveillance of the Helibrook AOC and approvals.

Why they would do this? Possibly to avoid any embarrassment when the report and safety issues are reviewed by ICAO?

Incidentally the safety issues from the Croc-o-shite report are still yet to be given an issue date and/or to listed on the ATSB safety issues and actions database - WTD? 

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 12-15-2023

Popinjay's Croc-o-shite report: The systemic investigation that wasn't?? - 

Courtesy CH9 ACA:


Popinjay (from 02:35): "The helicopter was likely not refuelled..."

Plus via the ABC:

Quote:Celebrity crocodile wrangler Matt Wright has been committed to stand trial in the Northern Territory Supreme Court on a charge of attempting to pervert the course of justice.

The charge is related to alleged events following a helicopter crash which killed his friend and television co-star Chris "Willow" Wilson in 2022.

Mr Wright, 44, was not present at the time of the crash and has strenuously denied all allegations.

Both Mr Wright and Mr Wilson starred in the National Geographic television series Outback Wrangler and Netflix show Wild Croc Territory.

Mr Wright appeared in the Darwin Local Court this morning for a brief committal hearing, where he was supported by his wife and legal team.

He faces a string of other charges, including fabricating and destroying evidence, which will be heard in the Darwin Local Court in June next year.

"I'm hopeful the remaining charges will all be withdrawn once this charge is dealt with next year," Mr Wright said in a statement.

In a brief hearing following Mr Wright's, helicopter pilot Michael Burbidge pleaded guilty to a charge of destroying evidence.

He was not piloting the helicopter that crashed.

Charges against Mr Burbidge of attempting to pervert the course of justice, fabricating evidence and making a false declaration were withdrawn.

Former NT Police officer Neil Mellon also pleaded guilty to a charge of destroying evidence, while his other charges — attempting to pervert the course of justice and making a false declaration – were withdrawn.

He will return to court in March for submissions and sentencing.

Separately, Mr Mellon faces 32 unrelated allegations including disclosing confidential information, unlawfully accessing data, obtaining benefit by deception and numerous weapons charges.

His separate matter will next be heard in the Darwin Local Court in February.

This week Mr Wilson's widow, Danielle Wilson, filed a separate civil suit against Mr Wright's company and Australia's aviation safety regulator over the fatal chopper crash.

An application filed with the Federal Court lists Helibrook and the Civil Aviation Safety Authority (CASA) as respondents.

The ABC understands Ms Wilson seeks damages, interest, costs, interest on costs and other orders as the court sees fit.

"In a brief hearing following Mr Wright's, helicopter pilot Michael Burbidge pleaded guilty to a charge of destroying evidence.."

...Former NT Police officer Neil Mellon also pleaded guilty to a charge of destroying evidence, while his other charges — attempting to pervert the course of justice and making a false declaration – were withdrawn.

He will return to court in March for submissions and sentencing.

Separately, Mr Mellon faces 32 unrelated allegations including disclosing confidential information, unlawfully accessing data, obtaining benefit by deception and numerous weapons charges..."

Related posts from the UP:

Quote:Ascend Charlie

Quote:CASA-approved safety management system was not being used to systematically identify and manage operational hazards,”

What a surprise.

Quote:The ATSB also found that CASA delegates removed crucial conditions from crocodile egg collecting authorisations, making it more likely the sling person would be killed if the helicopter’s engine failed.

There will be some world-class ducking and weaving going on in CA$A.

---

Cloudee

Quote:Originally Posted by Nescafe

Not a bad description for an operator that fudges maintenance, drains fuel from a crashed helicopter to divert blame and harasses a pilot in his hospital bed, allegedly.

Old mate was in court today. A couple of accomplices have pleaded guilty to destroying evidence from the crashed chopper. NT news today.

Michael Burbidge pleads guilty to destroying evidence after chopper crash that killed Chris Wilson

Prosecutor Steve Ledek asked that the details of the offending be suppressed to ‘preserve the state of the evidence’ against Outback Wrangler star Matt Wright in the Supreme Court.

Next from "X", I note that lawyer Peter Carter (from Carter Capner Law, Brisbane) was interviewed, on channel 7 'Sunrise', in regard to the Croc-o-shite legal wrangling:

Quote:Watch Peter Carter, director of Carter Capner Law on Sunrise talking about Outback Wrangler Matt Wright facing court over a series of charges involving the fatal helicopter crash that killed his Netflix co-star Chris Wilson.

#aviation #helicopter #accident #legal #lawyer

Note Carter's references to Chris Wilson's widow and her chances of success in suing CASA rather than the operator...

In what would be close to world record time for the ATSB to complete a systemic investigation, with all of this legal criminal and potential civil action, makes it even more 'passing strange' that the ATSB released the final report when they did??

This brings me to an earlier ABC article (13 Jan 2023) that timelines some more aberrations and disconnections with the Croc-o-shite cover-up investigation:

Quote:Australian Transport Safety Bureau upgrades investigation into NT helicopter crash that killed Chris 'Willow' Wilson



Key points:

• The ATSB originally anticipated the release of findings in late 2022
  
• Its investigation coincides with multiple court cases relating to the crash, including one involving celebrity crocodile wrangler Matt Wright
  
• Mr Wright "strenuously denies" any wrongdoing in relation to the crash
  

---

Transport bureau upgrades investigation

The date of release for the ATSB report has been pushed back, the authority confirmed, due to the investigation being "upgraded to a systemic level investigation".

A systemic response is the ATSB's second highest level of investigation, topped only by a "major investigation" which would potentially involve a "large number of casualties".

An ATSB spokesman said the authority could not go into specifics on why the investigation had been upgraded as it was still ongoing, but said investigations were upgraded to systemic "when they are expanded to consider factors relating to organisations, processes, systems, cultures" and more.

A description on the ATSB's website said systemic investigations "have a broad scope and involve a significant effort collecting evidence across many areas".

"The breadth of the investigation will often cover multiple organisations," the description said.

"Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes."

Hmm...wonder what?/who? made Popinjay upgrade the investigation nearly a year in?

Some key date info: in late 2022 Popinjay advised “before the end of the year”; Jan 2023 he extended and upgraded it to “before” April 2023, then released it late NOV 23.

Basically, Jan 2023 - Popinjay makes a 3 month extension, it’s actually released 11 months after based on his BS ‘systemic’ excuse for the delay. The outcome is a report that doesn’t analyse systemic issues.

Regardless, it appears that the AAI aspect is secondary to everything else, and is being manipulated for other needs - there’s a lot in this and it’s very ‘murky’??

Next, in reference to my previous post:  [/url]



Why did the rushed final report not include:  [url=https://auntypru.com/forum/showthread.php?tid=217&pid=14040#pid14040]Chalk & Cheese: S is for? - Surveillance. 

Meanwhile in WA, despite the many systemic issues including negligent CASA oversight, the Coroner has refused to open up a proper inquest into the tragic R44 accident in Broome that took the life of Amber Miller:

Quote:No coronial inquest into fatal Broome chopper crash in which a 12-year-old girl and the pilot died

Key points:

• A WA Coroner has decided not to hold an inquest into the death of Amber Jess Millar, who died in a helicopter accident in Broome in 2020
  
• The 12-year-old girl and pilot Troy Thomas were killed in an accident that shook the Kimberley town
  
• Jess' parents Clint and Fiona Benbow can appeal the decision but have declined to comment
  

   

Now watch the first 27:19 minutes of this Senate Estimates session:


MTF...P2 

---

RE: The search for investigative probity. - Peetwo - 12-22-2023

Popinjay leaks Skerrit Ghost review; & CASA author ATSB corporate plan?

Remember this?

(11-10-2023, 08:02 AM)Peetwo Wrote:  Miniscule Dicky King trainwreck interview: Skerritt the panacea for Transport Safety agencies?? 

Via Su_Spence saga thread:

(11-09-2023, 06:14 PM)Peetwo Wrote:  Miniscule Dicky King weighs in on CASA ineptitude on Broome R44 fatal?? - 

Via LinkedIn... :

---

Australian Aviation
53,678 followers
2h •

Transport Minister Catherine King has defended CASA’s handling of the company responsible for 2020’s fatal crash of a Robinson R44 helicopter which killed a young girl.

The minister told ABC Radio in Perth this week that CASA “can’t be everywhere” in response to questions from host Nadia Mitsopoulos over whether the crash, which took the life of 12-year-old Amber Jess Millar (pictured), could have been prevented had CASA been more proactive.

https://ow.ly/xgqe50Q5Mti

Link for the transcript of the Perth (trainwreck) ABC radio interview:  https://minister.infrastructure.gov.au/c-king/interview/radio-interview-abc-perth

Note this was the sub-heading for that interview:

Quote:INTERVIEW

Tuesday 07 November 2023

Subjects: Crash in Daylesford, Electrifying Perth's buses, sustainable aviation fuel

Note there is no mention about CASA's failings in the Broome R44 fatal, this is despite the transcript revealing that this was the dominant interview subject matter:

Quote:NADIA MITSOPOULOS: Okay. Catherine King is with me, the Minister for Infrastructure, Transport, Regional Development and Local Government. Let’s stay on the issue of aviation, because you would be familiar with that chopper crash in Broome a few years ago that killed the pilot, Troy Thomas, and 13‑year‑old Amber Millar.

Now the Australian Transport Safety Bureau did a report into that crash, it described the pilot as having a risk‑taking appetite. It also found six unreported incidents and accidents involving Mr Thomas. Are you confident there are no more matters to be canvassed concerning Troy Thomas?

CATHERINE KING: Well, what I will say is that it’s really important that we have an independent Civil Aviation Safety Agency that focuses on safety, and the ATSB, whilst they did not find any findings against CASA, what I’ve asked CASA to do is to look at this incident, make sure that there is any other lessons that they would learn from that, and if there’s anything further they need to do, that they need to do so.

I’ve met over the phone with Clint and Fiona, so –

NADIA MITSOPOULOS: Who are 12‑year‑old Amber’s parents?

CATHERINE KING: Unimaginable, unimaginable, and I’ve got a 15‑year‑old, I think all of us can just imagine, you know, what we would feel in those circumstances, and have put them in touch with the head of CASA, Pip Spence, they’ve been talking to her and they’re in touch fairly regularly.

CASA has said publicly, obviously had the pilot survived the accident, they would have taken action against the pilot, but that unfortunately they’re not able to do, he lost his life in that incident as well. They’ve said that really clearly that’s what would have happened.

But again, it’s whether there was any further action in terms of the maintenance of this craft, whether there’s more, broader systemic things that they think they need to do. So they’re continuing to look at that, but ATSB have finished its investigation and didn’t find any direct findings against CASA, and really what ATSB will do, and they’re the investigators, will look at whether there’s any systemic failures that need further work.

NADIA MITSOPOULOS: Isn’t the failure here, and I appreciate ATSB has completed their report and they’ve done what was asked of them, isn’t the issue here the fact that there were another six unreported incidents and accidents? I mean this involved a chopper going into the water, one of those incidents involved somebody being injured. I mean, I guess what people are trying to understand is how can that happen, that five or six incidents go unreported.

CATHERINE KING: Well, exactly. To some extent I would say it is absolutely incumbent on everyone in aviation, if there are incidents that occur, like we all have to operate safely. It is difficult for the ATSB or for CASA to be aware of something if it’s not reported.

NADIA MITSOPOULOS: But what about if CASA was more proactive, maybe they would have learnt about it, because the problem is they are reactive not proactive.

CATHERINE KING: Well, I think you could say that about all of our safety systems to some extent, but what I –

NADIA MITSOPOULOS: That’s not good.

CATHERINE KING: – what I’d say with this is they can’t be everywhere. Like they just can’t, you know, we can’t have investigators everywhere, but what we can have is eyes on the industry everywhere, and that is incumbent on all of us, if we see something, report it, if we see that there’s unsafe action, or you think there is unsafe action in the industry; general aviation is a big sector, it is everywhere, in small airports, small properties, all the way across the country, it is really important that people report incidents if they think something is happening and report that to CASA so they can investigate, cause they just can’t be everywhere.

NADIA MITSOPOULOS: But there’s no presence of CASA in the Kimberley. That’s been ‑  and whenever we talk about this I get ‑ and I’ve already got text messages coming in from people saying that there’s no eyes on the aviation industry in the Kimberley. Is there anyone from CASA there?

CATHERINE KING: I’d have to go back and check that, but what I would say is we are all eyes, so wherever you are, you are an eye on the industry, and so it’s important to report that to CASA. CASA, as I said, are still looking at whether there are other things they need to do. One of the things also –

NADIA MITSOPOULOS: Could they be more proactive?

CATHERINE KING: I think ATSB did not find that, but what I would –

NADIA MITSOPOULOS: But I’m asking you.

CATHERINE KING: No, no, and what I would say is I have got at the moment John Skerritt who used to head up the Therapeutic Goods Administration, I appointed him when we were last in government, it’s a regulatory agency around the safety of medicines and products. He has now left the TGA, and he is undertaking a piece of work for me across CASA, ATSB and AMSA, which is the Australian Maritime Safety Agency, to look at a couple of things. First is sustainable funding models, so we need to make sure we’ve got enough resources so that they can do their jobs, and also to look at the regulatory environment in which they operate in.

So he’s having a look at that for me at the moment, and certainly if there’s anything further that we need to do, or if CASA identifies anything further they think we need to do, then I am up for that.

NADIA MITSOPOULOS: It’s 17 past 10. I’ve got the Infrastructure and Transport Minister, Catherine King, with me. So are you aware that CASA is putting another two staff in WA, are you aware of that?

CATHERINE KING: Because they’re independent of me, they have a separate board and they are independent of Government, they organise their own operational arrangements, so they wouldn’t inform me about what they’re doing, but if they are doing that, then that is a good thing. That would be a matter for the board and for the CEO to determine that.

NADIA MITSOPOULOS: Does it surprise you that CASA’s not had a presence up there?

CATHERINE KING: I think that –

NADIA MITSOPOULOS: And we know there are problems with the aviation industry.

CATHERINE KING: Yeah. Well, if there’s – and certainly if there are systemic problems, particularly up north that CASA is identifying, and that is a good thing, if they’re putting more staff up there, then that is a good thing.

NADIA MITSOPOULOS: What type of new evidence would warrant a fresh inquiry into this issue?

CATHERINE KING: I’m not an investigator, and it really wouldn’t be something that would be ‑ that’s not for me to determine. What I have said, you know, and in the discussions we’ve had with Pip Spence, particularly the head of CASA, is, you know, if there are things that they identify they can do better, then they need to look at that, and you know, talk to me about what they need to be able to do that, and so that’s really where that’s up to at the moment.

NADIA MITSOPOULOS: The Coroner here has refused a public inquest into that fatal crash, and it was hoped he would also look beyond just that crash and safety issues generally in the particularly tourism aviation industry. Did you make any representation to support a Coronial inquest?

CATHERINE KING: It would be inappropriate for me to do that. They are obviously independent, they’re part of the WA judicial system as well, it would be inappropriate for me to do that.

NADIA MITSOPOULOS: Are you meeting with the Benbow family while you’re in Perth?

CATHERINE KING: Not while I’m in Perth, but as I said, I have met with them, they’ve met via phone with staff from my office, and we’ve put them in touch with Pip Spence.

NADIA MITSOPOULOS: Are you concerned about the mounting – well, there is concern at CASA regarding short staffing, bloated work backlogs, key unions involved with CASA, their members walking off the job; are you concerned about CASA’s ability to do their job properly, because these are very serious concerns, when people go on strike, you got to listen.

CATHERINE KING: They’re currently in EBA negotiations at the moment, so I do ‑ they are in Enterprise Bargaining Agreement negotiations at the moment, so some of that commentary has that as a backdrop, so but what I –

NADIA MITSOPOULOS: So are you saying it’s not genuine, the concerns?

CATHERINE KING: – would say is there’s an EBA negotiation happening at the moment, but the other thing that is happening, as I said, is we’ve asked John Skerritt to have a look at the sustainable funding models for the safety agencies across my portfolio.

NADIA MITSOPOULOS: And what about aviation in the tourism industry; does that need to be specifically looked at?

CATHERINE KING: Well, I mean it’s very broad, and so really, you know, there are a lot of general aviation operators in the tourism sector, and they all have requirements under CASA regulations, I mean they all do have those.

So if there are people who are operating outside of the regulations, then you know, that is something that is of concern to us, and as I said, in this particular incident CASA has said very clearly, had the pilot survived, then there would have been ‑ they would have taken some action against him.

NADIA MITSOPOULOS: I appreciate what you’re saying, but isn’t the question here who is checking them? You can have all the regulations you want, but they’ve got to be enforced, and the whole criticism here is about the lack of oversight, no one’s checking.

CATHERINE KING: And you cannot have a CASA officer at every airport, in every single plane right the way across the country. That is why it is incumbent on the sector itself to report; if people see anything they need to report. Obviously CASA needs to be able to do its job, it needs the resources to do its job, and that’s my job –

NADIA MITSOPOULOS: But it needs to be more proactive, doesn’t it –

CATHERINE KING: – to make sure that’s the case.

NADIA MITSOPOULOS: – to be looking at the industry. I’m not saying you have an officer in every plane, but there’s been virtually no presence in WA.

CATHERINE KING: But I would say that it, you know, like they do investigate, you know, they do investigate. But again, if there are things that need to be done to improve, not just CASA’s presence, but what they are doing in terms of general aviation more broadly, then, you know, I’m up for that, and part of what John Skerritt will be looking at is to look at whether the systems are working as they should be, not just at CASA but across all of my safety agencies.

(ABC Radio audio link - HERE. The Miniscule DK interview starts at approximately the 01:36:30 mark.)

Looking through previous episodes of the Nadia Mitsopoulos morning radio program, I note that last week she focused on the Broome R44 crash that killed 12 year old Ambar Miller: https://www.abc.net.au/listen/programs/perth-mornings/mornings/103036226 (from 05:15 minutes)

Quote:The parents of 12-year-old Amber Millar who died in a helicopter crash in Broome in 2020 are devastated the WA Coroner has decided not to hold an inquest in to the tragedy.

DK quotes: ".. I have got at the moment John Skerritt who used to head up the Therapeutic Goods Administration, I appointed him when we were last in government, it’s a regulatory agency around the safety of medicines and products. He has now left the TGA, and he is undertaking a piece of work for me across CASA, ATSB and AMSA, which is the Australian Maritime Safety Agency, to look at a couple of things...as I said, is we’ve asked John Skerritt to have a look at the sustainable funding models for the safety agencies across my portfolio. ...part of what John Skerritt will be looking at is to look at whether the systems are working as they should be, not just at CASA but across all of my safety agencies..."

No doubt in my mind that the Miniscule did not originally intend to spill the intel on John Skerritt appointment. This spill was purely as a result of a tenacious reporters relentless questioning on the major deficiencies and duplicity of CASA rotary wing operator/pilot oversight in the topend. (Refer this post for background on Su_Spence's sensitivity around this: Su_Spence's conflicted 'stating the bollocks' on Top-End Madness??)

From Google trolling I came across this Dept webpage: Australian Transport Safety and Investigation Bodies Financial Sustainability Review

Quote:Our transport safety bodies are world-renowned (  - yeah right) and the Australian Government is committed to ensuring they stay operationally fit-for-purpose and are sustainably funded to carry out their responsibilities.

The Australian Transport Safety and Investigation Bodies Financial Sustainability Review (the Review) will review the operations, consider potential efficiencies and options for cost recovery of the following bodies;

• Civil Aviation Safety Authority (CASA)
  
• Australian Transport Safety Bureau (ATSB)
  
• Australian Maritime Safety Authority (AMSA)
  

The Review will be undertaken over six months.

About the Review

The objectives of the Review are to identify, report and make recommendations on:

• The extent to which agencies’ operations and associated funding arrangements/mechanisms are fit for discharging their legislative and regulatory responsibilities, and whether any changes should be considered by Government.
  
• Government and non-government funding sources of safety and investigation bodies, together with current and future funding requirements (based on the efficient cost of delivery), including regarding any expected changes to each agency’s operating environment.
  
• Assessment of options for government and non-government funding sources, including through cost recovery, and their likely sectoral impacts.
  
• Opportunities for operational efficiencies, and how they could be implemented, including whether opportunities exist to implement risk-based frameworks or scale operations to adapt to changing circumstances.
  
• Any legislative or regulatory amendments required as a consequence of other recommendations made.
  
• The Reviewer will consult with relevant government and industry stakeholders. The Reviewer will provide a report to the Minister for Infrastructure, Transport, Regional Development and Local Government following the conclusion of the Review for consideration.
  

Terms of Reference

Read the Terms of Reference.

Hmm...wonder why such a significant review has not been made public nor mentioned by Betts, Su_Spence and CO, or questioned on by the Senate RRAT committee in the Supplementary Budget Estimates? The sinister answer is on the ToR webpage:

 

Quote:Date published: 24 October 2023

Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference

Document Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference—PDF (220.7 KB)
Document Australian Transport Safety and Investigation Bodies Financial Sustainability Review—Terms of Reference—DOCX (129.49 KB)

So the ToR wasn't published till the day after the RRAT Senate Estimates hearing and is still yet to be brought to the attention of industry and taxpayers, including the identity of the anointed Reviewer John Skerritt??

Of also 'passing strange' interest is there are 2 versions under 'Governance'/'Who will conduct the Review?'

From the ToR:

Quote:1.3 Governance

1.3.1 Role of the Reviewer

The Review will be conducted by a Reviewer with appropriate expertise in public sector financial, operations and
governance to be appointed by The Hon Catherine King MP, Minister for Infrastructure, Transport, Regional
Development and Local Government (the Minister).

The Reviewer will be responsible for the delivery of the final report to Government by early 2024, including
recommendations addressing the scope outlined above.

Secretariat support for the Review will be provided by the Australian Department of Infrastructure, Transport,
Regional Development, Communications and the Arts (the Department).

 

And from the review webpage:

Quote:Who will conduct the Review?

The Review is being undertaken by an eminent person with extensive expertise in public sector financial, operations and governance appointed by The Hon Catherine King MP, Minister for Infrastructure, Transport, Regional Development and Local Government (the Minister).

The Reviewer will be responsible for the delivery of the final report to Government by early 2024, including recommendations addressing the scope outlined above.

The Reviewer is being supported by a secretariat team within the Department of Infrastructure, Transport, Regional Development, Communication and the Arts.

Spot the difference?

I wonder when the review webpage was 1st made public?

Finally, the 'Reviewer':

Quote:Reviewer

Professor John Skerritt



Professor John Skerritt is a respected regulatory leader with extensive experience in strategic policy, operational and financing models for regulatory systems. He has led a number of regulatory functions across health, agriculture, veterinary and fisheries, and land and natural resource protection and emergency management areas. This includes supporting and implementing the results of major government reviews, modernising regulatory policies and operations including business and digital transformation, developing strengthened compliance and enforcement schemes as well as playing a lead role in the national and international harmonisation of regulation and regulatory practice.

He has extensive senior government experience, including 24 years in three Deputy Secretary/Deputy CEO roles - within the Australian Department of Health (including 10 years as Head of the Therapeutic Goods Administration), the Foreign Affairs and Trade Portfolio and within the Victorian Government.  Professor Skerritt also has significant experience on boards of international and national organisations, including as board chair and as chair of board audit committees.

Prof Skerritt is a Professor and Adjunct Professor respectively at the universities of Melbourne and Sydney and has a PhD and a University Medal from the University of Sydney, and international qualifications in management from London Business School and IMD Switzerland.

Hmm...didn't notice any references to transport safety, aviation or maritime safety investigation?? 

Still no official announcement from miniscule DK or her Department, however I did notice the Senator Gerard Rennick did make a Instagram post referring to Skerrit Ghost Review: https://www.instagram.com/p/CzaSI57rPh2/?utm_source=ig_web_button_share_sheet 

Quote:Can you believe this?

Skerritt has landed some plum job chairing a committee that will be nothing but a flick and tick exercise.

The RRAT Senate committee should be reviewing Infrastructure, not some unelected bureaucrat, especially Skerritt.

I have also discovered that DK was in fact not the 1st to leak the existence of the "Australian Transport Safety and Investigation Bodies Financial Sustainability Review". In fact the first person to make/leak (30 August 2023) an unofficial announcement of the review was Popinjay himself, in the current ATSB Corporate Plan:

Quote:Corporate Plan 2023-24



I am pleased to present the Australian Transport Safety Bureau (ATSB) Corporate Plan for the period 2023-24 to 2026-27.

This Corporate Plan has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. The Corporate Plan is also consistent with the Statement of Expectations 2023-25 (SOE) for the ATSB, as notified under Section 12AE of the TSI Act, by the Minister for Infrastructure, Transport, Regional Development and Local Government.

The SOE sets out clear expectations relating to the ATSB’s governance, strategic direction, key initiatives, and stakeholder engagement, such that the ATSB’s resources be used in an efficient, effective, economical, and ethical way, following best practice principles and guidelines. I look forward to continuing to work with the Government to ensure the ATSB remains well positioned to meet these expectations.

I note there have been calls stemming from several inquiries and associated reports seeking to extend the ATSB’s services through an expanded remit. The ATSB will continue to provide input into such inquiries although any decisions to change the ATSB’s operating parameters are a matter for Government. My priority, since becoming Chief Commissioner in late 2021, has been to ensure the ATSB is funded adequately to perform the role defined by its existing remit. In this context, the ATSB will actively participate in the recently announced Australian Transport Safety and Investigation Bodies Financial Sustainability Review, which will consider and evaluate the ATSB’s current operational and funding arrangements.

In the past 12 months the ATSB has continued to demonstrate itself as a highly-capable agency releasing a number of complex and industry-significant investigation reports that carry wide-ranging safety learnings to the relevant transport modes. One such example is the ATSB’s final report into the collision with terrain of a Lockheed C-130 large air tanker during the 2019-20 Australian bushfire season. That investigation produced multiple key safety lessons relating to the tasking and operation of large air tankers – an operation becoming more prevalent in Australian firefighting.

Another fine example from the last 12 months was our final report into an investigation of a rail collision in Far North Queensland, which resulted in multiple safety actions being taken. The collision occurred due to a brake pipe not being properly connected when the train was coupled, and our investigation also made findings around survivability aspects in how the locomotive was manufactured. Pleasingly, this led to action being taken by the operator, the industry standards board, and the locomotive’s design owner.

In the marine sector, we also finalised a significant investigation into the sinking of a pair of tugs in Devonport, Tasmania, after they were impacted by an Australian-flagged bulk carrier, when its crew failed to select the correct steering setting during a turn in the port’s swing basin. This investigation made findings – and resulted in safety action by the operator – relating to bridge resource management, a key component of all safe marine operations. It also reflected on the response by the port operator, with more safety lessons emerging for that side of the industry as well.

As a relatively small, operationally-focused agency, the ATSB needs to anticipate change and adapt to ensure we are meeting the needs of government, industry, and the travelling public. Accordingly, during 2023 we launched our inaugural strategic plan, detailed later in this report. This plan was developed from extensive work with staff from across the agency. It clearly identifies the key objectives, strategies, and actions to be given priority over the short to medium term, with a focus on:

• enhancing our products and stakeholder engagement for improving transport safety
  
• fostering organisational resilience
  
• affirming our role as the national transport safety investigator.
  

One area of that plan which has already yielded significant benefit has been a greater utilisation of audio-visual content. Through an expansion of the ATSB’s digital media production capabilities, we are able to develop more animations and videos to support our report releases. These products not only provide a better understanding for the audience already engaged in our reports; they also bring more people into the safety conversation, with high engagement levels across social media, and a high utility for television and online media outlets.

Over coming years, the strategic plan will aim to further improve the ATSB’s ability to provide greater value for persons and organisations seeking to use our products to take safety action.

Based on my interactions with a range of peer international safety investigation bodies since joining the ATSB, it is evident the agency remains highly regarded, and among the world’s leading transport safety agencies. I remain fully committed to continuing to work innovatively and collaboratively with all relevant stakeholders to enhance and amplify our contribution to improving transport safety, both domestically and internationally.

Angus Mitchell

Chief Commissioner and Chief Executive Officer

   
"recently announced" - Yet it took another month for EWB's Dept to publish the details of the review, a further month to publish the ToR, then  a further 2 weeks for EWB's crew to unofficially publish that Skerrit had the job and for DK to publicly leak both the existence of the review plus the identity of the imminent reviewer??

As a significant sidebar, in the course of tracking when the ATSB Corporate Plan was first created, I visited the document properties for the PDF version of the CP: https://www.atsb.gov.au/sites/default/files/2023-08/ATSB%20Corporate%20Plan%202023-24.pdf

Quote:Document properties
File name: ATSB Corporate Plan 2023-24.pdf
File size: 733 KB
Title: -
Author: Lloyd Petty
Subject: -
Keywords: -
Created: 8/29/23, 10:13:37 AM
Modified: 8/29/23, 10:13:54 AM
Application: Acrobat PDFMaker 23 for Word
PDF producer: Adobe PDF Library 23.3.20
PDF version: 1.6
Page count: 24
Page size: Varies
Fast web view: Yes

 

Note that the author's name is Lloyd Petty, this individual is a long term employee for CASA with his most recent listed on LinkedIn as:

Quote:Civil Aviation Safety Authority
7 yrs 9 mos

Manager, Resource Planning & Reporting

Why is a CASA officer writing the four year 'strategic plan' for a supposedly fully independent government statutory agency?

MTF...P2 

---

RE: The search for investigative probity. - Peetwo - 01-02-2024



Popinjay starts the BLAME GAME on Gold Coast Midair?? - 

The following despicable ATSB cover-up propaganda, is attributed to Popinjay... 

Quote:Interim transport safety report one year on from Gold Coast helicopter collision



The Australian Transport Safety Bureau has released an interim report detailing contextual information established as part of its ongoing investigation into the mid-air collision between two helicopters on the Gold Coast one year ago.

The report is intended to update the industry and public on the progress of the ATSB’s independent ‘no blame’ investigation, which is conducted with the goal of improving transport safety.

“To date, the ATSB has undertaken extensive work to understand and recreate the events of the day in order to identify and examine the context and risk controls that existed at the time,” Chief Commissioner Angus Mitchell said.

“The ATSB analysis framework looks at a hierarchy of factors arranged in their relative proximity to an event, and this investigation has so far concentrated on elements closest to the event: individual actions, vehicle/equipment performance, local conditions, and risk controls.”

This work has included interviews with key personnel and witnesses, the examination of both helicopters, maintenance logs, and postmortem information, a review of industry understanding of seat belt fitment, and analysis of ADS-B and radar flight tracking information, CTAF recordings, and video imagery.

“A large amount of the evidence gathered through this work is detailed in today’s interim report, and investigation into and analysis of many of these areas is ongoing,” Mr Mitchell said.

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites.

“A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” he said.

“It is important to note while this is a substantive and comprehensive interim report, the ATSB is yet to make formal findings as to the contributing factors that led to this accident as we are continuing our analysis of that evidence.”

Moving forward, Mr Mitchell said the investigation would consider whether any systemic factors contributed to, or increased risk in the accident.

“This will include consideration of the design of the operating environment and operating procedures, the onboarding and implementation of aircraft, change management, and the regulatory environment and input,” he explained.

The ATSB’s final report, which will include analysis, findings, and any recommended safety actions, is on track for an anticipated completion in the third quarter of 2024.

“This was a tragic accident, and it is our responsibility to make findings and drive safety actions, which reduce the likelihood of a similar occurrence in the future,” Mr Mitchell said.

The interim report notes several steps which have already been taken in response to the accident.

After reviewing its processes and procedures, Sea World Helicopters has implemented a new ‘pad boss’ traffic advisory role, added air traffic systems to each of its helicopters’ avionic systems, increased communication protocols, and taken steps to make its helicopters more visible.

Separately, the ATSB issued a Safety Advisory Notice in September, targeting aircraft lifejacket manufacturers and national aviation certification authorities.

“During this investigation, our investigators identified a potentially common lack of understanding in the broader helicopter tourism community about how constant wear lifejackets should be worn in conjunction with seatbelts,” Mr Mitchell explained.

“This correlated with a discovery that some passengers’ seatbelts were not fitted correctly in this accident, in part due to interference from their lifejackets – although we have not attributed this to the tragic outcomes in this case.”

Read the interim report: Mid-air collision involving Eurocopter EC130B4, VH-XH9, and Eurocopter EC130B4, VH-XKQ, Main Beach, Gold Coast, Queensland, on 2 January 2023

Publication Date 02/01/2024

The part in bold and underlined, what the hell was Popinjay bringing this up for?? The following is the ultimate effect that unbelievable ill informed, disassociated statement has had...

Courtesy Skynews, via YouTube: 

Quote:

Gold Coast helicopter crash: ATSB reiterates ‘zero policy’ approach to drugs

Aviation safety officials have reiterated a 'zero tolerance' approach to drugs after the pilot of a fatal crash in the Gold Coast was found to have traces of cocaine in his system.

The Australian Transport Safety Bureau issued its interim report on the incident on Tuesday.

Two Sea World tourist helicopters collided midair on January 2 2022.

The collision killed four people, including the pilot of one of the helicopters.

A further nine were injured.

The report also revealed that some seatbelts on the aircraft were not fitted correctly.

UDB! Popinjay needs to resign NOW! 



MTF...P2 

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RE: The search for investigative probity. - Sandy Reith - 01-03-2024

The finger pointing illustration sums up our dysfunctional system of aviation governance.
P2’s forensic analysis has once again prised open the lid on the can of worms that is government by independent bodies whose functions were once within Departments with responsible Ministers at head with direct oversight. The Westminster tradition with its proper, principled and pragmatic feature of the most direct line of responsibility between the governed and the governors has been discarded with predictable and now very obvious consequences. The Public Sector, that which used to be the Public Service, is a fat revolving door operation with some pointing of fingers in the blame game as P2 so ably exposes. But beyond that they are all conscious that this can’t go too far lest Ministers are forced to step in which could, just conceivably, place at risk the whole colossal gravy train and the salary factories of Canberra.

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RE: The search for investigative probity. - Kharon - 01-05-2024

First BRB Indaba.2024..

By demand, item #1 – the Gold Coast mid air. It comes with a warning 'beware the fury'. That fury being fully justified (IMO) the blame ducking shambles the ATSB and CASA have developed almost beggars imagination; it certainly beats logic and good 'over-sight' of an operation. Maybe some readers will understand 'what' exactly is involved with bringing a 'new' type' onto an operating certificate; under a CASA rule set. It ain't a stroll in the park; not by a long, long mile it ain't. Brutal amounts of paperwork being the least of it; management pressure to keep the ball rolling; - in short its no game for light weights. However, seems the CP got the job done, signed off and fully approved. Bar the one flaw; the one which proved to be fatal. Perhaps ATSB (with the aid of the useless, (expensive) German (expensive) tech video stropathon can define some very, very basic rules (cast ion stone, covered in blood) about why no one picked up the potential for 'conflict' between incoming and out going aircraft. One glance at the ATSB diagram clearly defines the oversight the busy CP (forgivably) made. But there is no excuse for CASA: their own words and tenet.

“See-and-avoid’, as a means of separation and collision prevention for two or more
vehicles, is an ancient principle and one that in the maritime environment predates
aviation by many centuries.

2.1.2 In the early history of aviation, see-and-avoid was the only means for avoiding collision,but as aviation advanced, its limitations have become apparent. Since the early days of flight, additional measures have been sought to reduce the risks of mid-air collision. In parallel with aviation, the maritime industry has adopted, where circumstances have warranted, many of the same means to avoid collisions on the water.

2.1.3 In modern aviation, see-and-avoid is the last line of defence, but usually not the only mechanism for avoiding a collision or an Airprox event

These questions should have been addressed by CASA early in the piece; discussed and 'sorted' prior to any operational approval; once again, take a look at the diagram provided and spot the obvious error. (No Choc Frogs). The company i.e. the CP would be very reluctant to 're-draft' and have 'accepted' and pay for an amendment to their manuals and procedures. CASA would have upped the ante and the charges and taken the God's own time to 'accept' the new procedures; the cost in time, work and money prohibitive. So, least said, soonest mended. Result – inevitable..........

After the Lord Mayors parade; the sweepers. Those left to sweep up the mess; a.k.a. The ATSB. If our wee bearded Popinjay (media hog) had any idea of what the professionals in 'air safety' thought of his antics; he'd probably buy a bigger hat, with a bias (and little in the way of cattle to match the ensemble). Deliberately, without a qualm, he gets into the brainless media and promotes the notion that 'chemicals' had a part to play in the event. BOLLOCKS – in Spades, redoubled. BOLLOCKS........

This bumptious, unqualified, self promoting, camera loving, kangaroo bothering weasel is so captured and so willing to spin and weave the CASA narrative into 'the media' that it is embarrassing' in the extreme. The BRB cannot believe that he has not been asked to 'depart' the fix and go back to translating 'Indon' weather forecasts, or whatever. Independent ?? Competent?? Honest??-  BOLLOCKS.........

I ask you, once again, study the diagram presented and define what the inevitable conclusion of that arrival and departure plan would be – sooner or later. With 20/20 hindsight the answer screams off the page; the company 'missed' it – CASA missed it – the ATSB have bamboozled the world into looking away from the realities. Bloody media so busy grabbing 'headlines' have missed the whole load of horse pooh – following Lord Mayors parade; like kids in a lolly shop.



Now I have to face and manage a hostile crew; perhaps Popinjay would accept an invitation to attend. Only be about two dozen there, and answer the only question that matters – WTD...

That is all, duty done – P7 wants to invite Spence along. Nope – they outlawed pilgrims v Lions hundreds of years ago – didn't they? Be fun though, sure enough.......

Toot – toot,,,,,,

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RE: The search for investigative probity. - Peetwo - 01-25-2024

Popinjay Supp Estimates 23-24 AQON (so far)?? -   

Via RRAT Supp Estimates webpage:

67. ATSB - Date Minister was advised of Mr Mannings term expiring

290. ATSB - involvement in the process of filling Board appointments announced in August and October

291. ATSB - Chief Commissioner Angus Mitchells involvement in retiring members or proposed appointments to Board

Quote:Senator Bridget McKenzie asked:

Was the Chief Commissioner, Angus Mitchell consulted or asked for his view on either the
retiring members or proposed appointments?

Answer:

Yes.

292. ATSB - Details of Chris Mannings appointment to Board

293. ATSB - Details of Mr Wilsons appointment to Board

296. ATSB - Chief Commissioners review of 2021-22

Quote:Senator Bridget McKenzie asked:

1. Chief Commissioner ’s review 2021–22 states that ATSB ‘flagged our ongoing concern
about collisions between trading ships and small vessels on the Australian coast’ following
an incident in February 2020. What additional actions have been taken to mitigate the risk
of these collisions?
2. In 2021-22 the ATSB failed to meet the performance criterion that ‘85% of safety issues
[are] addressed in the previous financial year’. Given that only 74% of safety issues were
addressed in 2021-22, what needs to happen to meet this performance criterion?
3. In 2021-22 the ATSB missed its target median times to complete short (8 months),
defined (16 months) and systemic (22 months) investigations. How can ATSB investigations
be completed within the target times?
4. Despite a substantial increase in air traffic, the ATSB received approximately $500,000
less in government funding in 2021-22 compared to 2020-21. Did this impact the agency’s
functions?

Answer:

1. There were three collisions between trading ships and small vessels between 2015 and
2018 and a further collision between a fishing boat and bulk carrier on 29 February 2020
(investigated by the Australian Transport Safety Bureau (ATSB) as MO-2020-001). That
investigation (and others previously) highlighted the importance of maintaining an
adequate look out and the value of surveillance technology to increase traffic
awareness. The ATSB continues to monitor such occurrences and notes that there have
not been any collisions related to inadequate look out over the last few years.

2. The ATSB is a ‘no-blame’ safety investigator and does not have any power to enforce the
addressing of safety issues identified during ATSB investigations. However, the ATSB
does work with safety issue owners to encourage appropriate safety actions, both
during an investigation and afterwards. Some safety issues take time to address,
especially when new regulations are involved. As such, safety issues will continue to be
addressed in later years. For 2021-22 this particular measure was not met as a number
of safety issues identified in that year rolled over into 2022-23 where they were
addressed. This is reflected in the 2022-23 ATSB Annual report which shows that for the
2021-22 year, 85 per cent of safety issues had been addressed.

3. The ATSB has been actively targeting the performance of investigation times, and this is
reflected in the 4-year decreasing median for Short and Defined investigations shown in
the 2022-23 ATSB Annual Report. Measures in place are restricting the number of active
investigations to an average of two per investigator, adherence to a project
management approach to investigations, and an even distribution of investigations
across three directors. In 2023, the ATSB strategic plan led to a dedicated Short
investigation team (to conduct the majority of office-based short investigations), and a
dedicated Data Recovery team, Safety Analysis and Research, Marine investigation team
and Rail investigation team. While there will always be some variability in the length of
investigations depending on complexity (especially the larger systemic investigations),
the above measures are expected to continue to reduce the median time of
investigations in the forthcoming years.

4. To ensure, as far as practicable, that the ATSB can resource the investigations it takes
on, the ATSB limits the number of investigations to an average of two per investigator
(although investigators work across multiple investigations). With the ATSB’s present
resourcing this accommodates approximately 90 investigations a year across aviation,
marine and rail. There are currently no budget measures associated with industry
growth, however the Australian Government provided an additional $4.6 million in the
2023-24 Budget (in addition to its ordinary annual appropriation) to allow ATSB to retain
a staffing base of 110 ASL and conduct safety investigations across all modes of
transport within its remit. The Government has commissioned a Review of Operations
and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies,
announced in the 2023-24 Budget, which is expected to make recommendations to
Government relating to agency resourcing.

298. ATSB - Locations of Commissioners and staff of ATSB

299. ATSB - Independent investigation of transport accidents in 2021-22

300. ATSB - Safety data recording analysis and research in 2021-22

Quote:Senator Bridget McKenzie asked:

What proportion of time and budget did the ATSB work on safety data recording, analysis
and research in 2021-22? 

Answer:

The ATSB does not break down its activities/resources into specific streams that would allow
it to isolate the resources allocated directly on safety data recording, analysis and research
in 2021-22.

301. ATSB - Fostering safety awareness knowledge and action in 2021-22

Quote:Senator Bridget McKenzie asked:

What proportion of time and budget did the ATSB work on fostering safety awareness,
knowledge and action in 2021-22? 

Answer:

The ATSB does not break down its activities/resources into specific streams that would allow
it to isolate the resources allocated directly on fostering safety awareness, knowledge and
action in 2021-22.

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-11-2024

Chalk & Cheese: French TV AS350 Helicopter mid-air v Seaworld midair?

The following 2015 Argentinian AAI final report, was recently brought to my attention by Aerossurance on LinkedIn:

Quote:French TV AS350 Helicopter Accident in Argentina (UPDATED with final accident report)

The mid air collision of two Airbus AS350 (H125) helicopters on 9 March 2015 resulted in the death of all 10 people on board during the filming of a French TV programme, Dropped, for TF1 in Argentina. The accident highlights the importance of risk assessment, planning and preparation for any aerial activity.

Two AS350s were involved, both from different local government bodies: LQ-CGK and LQ-FJQ. At least one is reported to have been a Helicopter Emergency Medical Service (HEMS) aircraft loaned to the film makers. Of the 10 people onboard, 3 were French sports stars, 5 French TV personnel and two local pilots. The accident happened near Villa Castelli in La Rioja province in north-west Argentina.  The area is in the foothills of the Andes and is about 1300m above sea level.

Moments Before the Mid Air Collision (Credit: JIAAC)

The Bureau d’Enquêtes et d’Analyses (BEA) has issued a statement:

Quote:

The BEA has been notified of the accident that occurred between two Airbus Helicopters AS 350’s in the province of Rioja in Argentina yesterday, Monday 9 March. The two helicopters, registered respectively LQ-FJQ and LQ-CGK, had eight French passengers and two Argentinian pilots on board.
In accordance with international provisions the BEA, representing the State of Design and Manufacture of the helicopters, will participate in the Safety Investigation that has been initiated by its Argentinian counterpart, the JIAAC (Junta de Investigación de Accidentes de Aviación Civil).
Two investigators from the BEA, accompanied by a technical adviser from Airbus Helicopters and a technical adviser from Turbomeca, are travelling to Argentina today.

Flight International have commented on video footage of the accident. Time have published a piece critical of the production company and French reality TV in general. https://www.youtube.com/watch?v=u1iKgZzPyXU

---

UPDATE 22 June 2015: NTSB has issued a report on another fatal accident, this time a Loss of Control – Inflight at night, while filming a reality television show for the Discovery Channel, involving Bell 206B N59518 in California 0n 10 Feb 2013: NTSB faults pilot, inspector in reality TV helicopter crash.  The filming was organised by the production company EyeWorks USA, which has since rebranded itself as 3 Ball Entertainment.

UPDATE 10 August 2015: In the case of the US accident, it is now reported that an out of court settlement has been reached. 

UPDATE 24 August 2015:  Another accident has occurred in the US and is covered in an article that looks at safety in TV.

UPDATE 13 December 2015: Another TV helicopter accident in Argentina is reported: MTV helicopter crash kills two in Argentina

JIAAC Safety Investigation Final Report

UPDATE 17 December 2015: The JIAAC accident report on the March 2015 collision has been issued.  The accident investigators stating” In an operation classified as aerial work, which involved the transport of passengers and air-air filming activity, there was an in-flight collision between the two participating aircrafts”. The collision was caused by the combination of  the following factors:

• Location of the helicopter that was filming (LQ-FJQ), from the “outside”, in the path of both aircrafts, that significantly limited the visual contact of the pilot who had to move forward in flight in order to film the target (LQCGK);
  
• Lack of a formal assessment of the safety risks for an unusual operation (filming and flight in proximity), which prevented the identification and analysis of the dangers inherent to that operation, and the adoption of mitigation actions, requirement not  equired by the current regulations;
  
• Deficiencies in the operation planning that led to the accident, including the failure of observing the “see and be seen” concept or an evasive maneuver if visual contact is lost between both aircrafts;
  
• Lack of formal procedures in accordance with the nature of the operations performed;
  
• The use of aircrafts whose public identification prefix does not imply providing logistics and aerial support for filming of a completely private nature;
  
• Ambiguity in the observance of regulations related to air operations of public aircrafts;
  

---

Mid Air Collision (MAC) Safety Resources

UPDATE 9 March 2019: Aerossurance has previously published:

• Military Mid Air Collisions
  
• Military Airprox in Sweden
  
• North Sea S-92A Helicopter Airprox Feb 2017
  
• Mid Air Collision Typhoon & Learjet 35
  
• USMC CH-53E Readiness Crisis and Mid Air Collision Catastrophe
  
• Avoiding Mid Air Collisions: 5 Seconds to Impact
  
• AAIB Highlight Electronic Conspicuity and the Limitations of See and Avoid after Mid Air Collision a UK accident where a light single fixed wing aircraft descended into a helicopter.
  
• Fatal Biplane/Helicopter Mid Air Collision in Spain, 30 December 2017
  
• A319 / Cougar Airprox at MRS: ATC Busy, Failed Transponder and Helicopter Filtered From Radar
  
• Merlin Night Airprox: Systemic Issues
  

Also:

• Airbus Helicopters AS350B3 I-EDIC engaged in heli-skiing and Jodel D.140E Mousquetaire IV F-PMGV collided in mid air over the Rutor Glacier in Italy.  Eight of the nine persons on board the two aircraft died
  

 
Here is the French BEA English translated version of the JIAAC final report: https://auntypru.com/wp-content/uploads/2024/03/BEA2015-0097.en_15-1.pdf

It took the Argentinians 284 days to complete this systemic investigation. The ATSB Seaworld fatal chopper accident is already at 435 days with no recent update indicating a final report will be published anytime soon...

Given the obvious similarities/parallels, I wonder will this report feature in the ATSB final report? 

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 03-28-2024

Like Chalk & Cheese: Homendy vs Popinjay (the latest Can'tberra Village idiot) -

Via the NTSB, Baltimore bridge collision accident:

Quote:31,100 views Streamed live on Mar 27, 2024

NTSB Chair Jennifer Homendy briefs the media on the NTSB investigation of a cargo ship striking and subsequent collapse of the Francis Scott Key Bridge in Baltimore, Maryland.

Compare that to this load of bollocks and self-serving BS...


Plus on the release of the Prelim report, released 35 days past ICAO Annex 13 compliance for release of a AAI Prelim report:

Quote:“The ATSB has released this preliminary report to detail the circumstances of this tragic accident as we currently understand them, but it is important to stress that we are yet to make findings,” said ATSB Chief Commissioner Angus Mitchell.

“Our findings as to the contributing factors to this accident, and the analysis to support those findings, will be detailed in a final report to be released at the conclusion of our investigation.”

Mr Mitchell said the preliminary report details factual information, including the accident’s sequence of events.

“The factual information detailed in this report is derived from interviews with survivors of the accident, including the surviving pilot and passengers, and witnesses; analysis of video footage and images taken by passengers on board both helicopters, onlookers on the ground, and CCTV from nearby buildings; examination of the wreckage of both helicopters; and a review of recorded radio calls and aircraft tracking and radar data.”

The preliminary report details that the helicopters were operating from two separate helipad facilities about 220 metres apart, a pad within the theme park, and a pad to the south at the operator’s own heliport, adjacent to the park. The 5-minute scenic flights were to follow the same counter-clockwise orbit, with the inbound helicopter, registration VH-XH9 (XH9) on approach to land at the heliport to the south and the outbound helicopter, registration VH-XKQ (XKQ) having departed the pad to the north from within the theme park.

The two helicopters collided at an altitude of about 130 feet, 23 seconds into the departing XKQ’s flight.

The main rotor blades of helicopter XKQ entered the forward cabin of XH9. XKQ broke apart in mid-air and impacted shallow water next to a sandbar. The pilot and 3 passengers were fatally injured, and 3 passengers were seriously injured. The helicopter was destroyed.

Helicopter XH9 sustained significant damage to the forward cabin, instrument console, and main rotor blades. The impact turned XH9 to the left, and the pilot continued with the momentum of that movement, completing a 270° descending turn to land on the sandbar below them near to XKQ. The pilot and 2 passengers were seriously injured, and 3 other passengers had minor injuries.

The helicopters were operating in non-controlled airspace where pilots use a common traffic advisory frequency (CTAF) to make radio calls to announce their position and intentions, and, as required, to arrange separation with other aircraft.

The report details the radio calls made by the pilot of the returning helicopter XH9, and that as they tracked south over the Broadwater, that the pilot saw passengers boarding XKQ as it was preparing to depart.

The pilot of XH9 recalled that their assessment was that XKQ would pass behind them, and that they did not recall the pilot of XKQ making a standard “taxiing” call announcing their intention to depart.

“This does not necessarily mean that a taxi call was not made, and the ATSB investigation will undertake a detailed analysis of the nature of the radio calls made,” Mr Mitchell noted.

The report also details that the pilot of XH9 did not see XKQ depart from the park helipad.

While video footage taken by passengers in both helicopters on mobile phones contained images of the other helicopter, this does not mean that the other helicopter was visible to either pilot.

“The investigation will look closely at the issues both pilots faced in seeing the other helicopter,” Mr Mitchell said.

“We have already generated a 3D model of the view from the pilot’s seat from an exemplar EC130 helicopter which we will use as part of a detailed visibility study to help the investigation determine the impediments both pilots faced in sighting the other helicopter.”

Mr Mitchell said the investigation will also look more broadly beyond the issues of radio calls and visibility.

“The ATSB will also consider the operator’s procedures and practices for operating scenic flights in the Sea World area and the process for implementing the recently-acquired EC130 helicopters into operation, and will review the regulatory surveillance of the operator and similar operators.”

The investigation would also look at the use of traffic collision avoidance systems (TCAS). There was no requirement for the helicopters to be equipped with a collision avoidance system, and while both accident helicopters were fitted with TCAS, those systems had not been fully integrated in the accident helicopters (as they had with the operator’s other helicopters), and according to the operator’s pilots were of limited benefit when operating near and on the helipads.

“This will be a complex and comprehensive investigation.

“However, if at any time during the course of the investigation the ATSB identifies a critical safety issue, we will immediately share that information with relevant parties so they can take appropriate safety action.”

And for the anniversary interim report, this manufactured Popinjay bollocks press release:

Quote:Interim transport safety report one year on from Gold Coast helicopter collision



The Australian Transport Safety Bureau has released an interim report detailing contextual information established as part of its ongoing investigation into the mid-air collision between two helicopters on the Gold Coast one year ago.

The report is intended to update the industry and public on the progress of the ATSB’s independent ‘no blame’ investigation, which is conducted with the goal of improving transport safety.

“To date, the ATSB has undertaken extensive work to understand and recreate the events of the day in order to identify and examine the context and risk controls that existed at the time,” Chief Commissioner Angus Mitchell said.

“The ATSB analysis framework looks at a hierarchy of factors arranged in their relative proximity to an event, and this investigation has so far concentrated on elements closest to the event: individual actions, vehicle/equipment performance, local conditions, and risk controls.”

This work has included interviews with key personnel and witnesses, the examination of both helicopters, maintenance logs, and postmortem information, a review of industry understanding of seat belt fitment, and analysis of ADS-B and radar flight tracking information, CTAF recordings, and video imagery.

“A large amount of the evidence gathered through this work is detailed in today’s interim report, and investigation into and analysis of many of these areas is ongoing,” Mr Mitchell said.

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites.

“A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” he said.

“It is important to note while this is a substantive and comprehensive interim report, the ATSB is yet to make formal findings as to the contributing factors that led to this accident as we are continuing our analysis of that evidence.”

Moving forward, Mr Mitchell said the investigation would consider whether any systemic factors contributed to, or increased risk in the accident.

“This will include consideration of the design of the operating environment and operating procedures, the onboarding and implementation of aircraft, change management, and the regulatory environment and input,” he explained.

The ATSB’s final report, which will include analysis, findings, and any recommended safety actions, is on track for an anticipated completion in the third quarter of 2024.

“This was a tragic accident, and it is our responsibility to make findings and drive safety actions, which reduce the likelihood of a similar occurrence in the future,” Mr Mitchell said.

The interim report notes several steps which have already been taken in response to the accident.

After reviewing its processes and procedures, Sea World Helicopters has implemented a new ‘pad boss’ traffic advisory role, added air traffic systems to each of its helicopters’ avionic systems, increased communication protocols, and taken steps to make its helicopters more visible.

Separately, the ATSB issued a Safety Advisory Notice in September, targeting aircraft lifejacket manufacturers and national aviation certification authorities.

“During this investigation, our investigators identified a potentially common lack of understanding in the broader helicopter tourism community about how constant wear lifejackets should be worn in conjunction with seatbelts,” Mr Mitchell explained.

“This correlated with a discovery that some passengers’ seatbelts were not fitted correctly in this accident, in part due to interference from their lifejackets – although we have not attributed this to the tragic outcomes in this case.”

Read the interim report: Mid-air collision involving Eurocopter EC130B4, VH-XH9, and Eurocopter EC130B4, VH-XKQ, Main Beach, Gold Coast, Queensland, on 2 January 2023

Mr Mitchell noted the evidence includes a toxicology report for the fatally injured pilot, showing a positive result for low levels of cocaine metabolites. - “A forensic pharmacologist engaged by the ATSB has stated that the very low concentrations of these metabolites suggest exposure was not likely to have occurred in the 24 hours prior to the accident, and it is unlikely there would have been impairment of the pilot’s psychomotor skills,” This statement led to further defaming of the dead Chief Pilot:


Hmm...don't believe Homendy would be so stupid as to be led down that particular 'blame game' rabbit hole...

MTF...P2

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RE: The search for investigative probity. - Peetwo - 04-18-2024

Popinjay to the rescue?? -

Via LinkedIn:

Quote:Australian Transport Safety Bureau

Along with the Australian Maritime Safety Authority we are encouraging general and recreational aircraft owners to take advantage of the government’s ADS-B rebate program before it closes on 31 May 2024.

To incentivise voluntary uptake of ADS-B installations in Australian–registered aircraft operating under VFR, the government is providing a 50 per cent rebate on the purchase cost – capped to $5,000.

Take advantage of this generous rebate to equip your aircraft with ADS-B to see and be seen, before the offer ends on the 31 May.

Read the guidelines and determine your eligibility for a rebate:

Plus via Oz Flying:

Quote:ATSB and AMSA weigh in on VFR ADS-B Rebate

16 April 2024



The Australian Transport Safety Bureau (ATSB) and the Australian Maritime Safety Authority (AMSA) have today issued a statement encouraging owners of VFR aircraft to take advantage of the ADS-B rebate on offer from the Federal Government.

With the 50% or $5000 rebate scheme due to expire on 31 May, very few aircraft owners have taken advantage of the scheme which began on 1 June 2022.

In total, to 25 February this year, 1357 out of 1516 grant applications have been approved and paid out, but that represents only a small portion of Australia's VFR fleet given that the rebate is also open to recreational aircraft.

ATSB Chief Commissioner Angus Mitchell and AMSA CEO Mick Kinley were both keen to remind pilots of the advantages of ADS-B and urged aircraft owners to take the opportunity presented by the rebate scheme.

“The ‘see and avoid’ principle for pilots has known limitations," Mitchell said, "and the use of ADS-B IN with a cockpit display or an electronic flight bag application showing traffic information greatly improves a pilot’s situational awareness and enhances the safety of their flight.

“While there were a number of contributing factors, the need for improved situational awareness for pilots was evident during our investigation into the mid-air collision of two IFR training aircraft near Mangalore Airport in 2020.

"While both aircraft involved in the collision were operating under instrument flight rules (IFR) and equipped with ADS-B OUT, neither aircraft were equipped with ADS-B IN systems.”

Mick McKinley pointed out that ADS-B systems also have the ability to assist AMSA conduct search and rescue operations when aircraft and crew are in distress.

"The accurate positional data available from ADS-B can also assist in managing life-saving search and rescue (SAR) operations undertaken by AMSA, helping to guide first responders to a location with greater precision to affect a rescue," he explained.

"ADS-B data is another valuable tool used for SAR operations in Australia which helps to improve our ability to save lives.

“For aircraft in distress that are equipped with ADS-B, AMSA’s Joint Rescue Coordination Centre Australia will use the aircraft’s last known ADS-B position to refine a distress location.

"ADS-B can also provide enhanced traffic conflict data in a search area that may involve multiple SAR aircraft to enhance the safety of those involved in the response.”

Although the rebate scheme has been open for nearly two years, it has been hampered by poor avionics availability early on and ongoing shortages of qualified engineers to fit panel-mounted equipment.

With the rebate deadline looming in just over a month, the Federal Government has not committed to extending the program for a third year, but instead has said they are "monitoring the program's uptake to ensure it is fit for purpose."

Also from PJ HQ another couple of bollocks one-sided OP Media Releases, one from Stewie Macleod:

Quote:Near accident at Gold Coast emphasises importance of stable approaches and early go-around decisions



A Cessna 172 struck the ground and nearly collided with hangars while going around following a fast and long landing on Gold Coast Airport’s shorter cross runway, an ATSB investigation report details.

On the afternoon of 6 February 2024, a Cessna 172R with a student pilot and flight instructor on board was returning to the Gold Coast at the end of a training flight, with the student receiving an initial air traffic control clearance to track direct to runway 32 (the southern end of Gold Coast Airport’s main runway).

About 40 seconds after that initial clearance, the student and instructor then accepted an amended clearance to track to the shorter runway 35 at ‘best speed’.

Then, when the Cessna was at about 1,000 ft and 1.9 nautical miles from the runway 35 threshold, air traffic control directed the aircraft to maintain ‘best speed all the way in to crossing the runway’, and the instructor – unsure how to comply – directed the student to reduce throttle to idle and lower the aircraft’s nose.

“The aircraft subsequently passed about 100 ft above the runway threshold at about 25 kt faster than the normal approach speed,” ATSB Director Transport Safety Stuart Macleod said.

“Unable to slow the aircraft down before the runway’s end, the instructor attempted to turn onto taxiway Golf, but the aircraft skidded onto the grass, and the instructor elected to conduct an emergency go-around.”

During the go-around the aircraft’s fuselage struck the ground, and the pilot heard the stall warning horn, so lowered the nose slightly, narrowly clearing a row of hangars.

“Landing with excessive speed is likely to result in the aircraft floating, landing long on the runway, bouncing and/or ballooning, all of which increase the risk of a landing mishap,” Mr Macleod said.

“Although not standard phraseology, air traffic controllers may ask pilots to maintain ‘best speed’, and it is up to the pilot to determine what is best in this context, and more generally advise if an instruction is unclear or cannot be complied with.”

The ATSB final report notes the aircraft exceeded the speed for a stabilised approach, but the instructor did not conduct a go-around prior to landing, or while on the runway.

“When operating in visual meteorological conditions, if an approach is not stabilised by the height specified by the operator – or generally by about 500 ft above the ground, or the approach becomes unstable after that point, go around,” Mr Macleod said.

“Pilots are to always be ready to conduct a go‑around during the approach if any desired flight parameter, such as aircraft configuration, vertical speed, airspeed, or attitude, cannot be achieved.” 

Read the final report: Taxiway excursion, ground strike and near collision with terrain involving Cessna 172R, VH-EWW, at Gold Coast Airport, Queensland on 6 February 2024

Publication Date: 17/04/2024

And from our resident aviation safety Super Hero and Guru Popinjay...

Quote:Pilot incapacitation incident highlights importance of supplemental oxygen use



A pilot incapacitation incident on a Boeing 717 while the aircraft was on approach to land at Hobart last June reminds pilots to be alert to the potential hazards of odours and fumes and to not hesitate to use supplemental oxygen.

The serious incident occurred on 6 June 2023 when the QantasLink aircraft, operated by National Jet Systems, was operating a scheduled passenger service from Sydney with 5 crew and 54 passengers on board.

About 10 NM from Hobart, the flight crew noticed a chlorine odour emitting from the flight deck air-conditioning vents for about 10 seconds.

Shortly after, the captain experienced hypoxia-like symptoms, and assessed themselves unfit to continue as pilot flying, and handed over duties to the first officer.

The captain later described the symptoms as fogginess of thought, confusion, deteriorating situational awareness, weakness and tingling in the arms and legs, and narrowing of vision.

Then prior to touch down, the first officer noticed their reaction to an aircraft deviation was slowed, and they started to feel ‘hazy’.

Due to the impending landing, and perceived difficulties of donning the mask, supplemental oxygen was considered but not used, the report from the ATSB investigation into the incident details. A go-around was also considered but rejected following an assessment that continuing the landing was the safest course of action.

After landing and shutting down the aircraft, both pilots reported persistent headaches, and they were assessed by a company doctor via teleconference, during which the doctor observed that the captain’s speech was noticeably affected, consistent with impairment. The captain then attended hospital for further testing.

“This incident is a reminder to pilots to be alert to the potential hazard posed by odours and fumes, and to not hesitate to use supplemental oxygen,” ATSB Chief Commissioner Angus Mitchell said.

“The use of oxygen is a proven mitigating action in the case of environmental hazards and its rapid use ensures flight crews’ physical and mental capacity is maintained.”

The ATSB investigation also identified that while the cabin air quality events procedure had been conducted earlier in the flight, after cabin crew reported a chlorine odour and symptoms during the climb out of Sydney, this procedure did not consider the possible application of the smoke/fumes procedure, or the incapacitation procedure.

“This increased the risk of flight crew being adversely affected by such an event during a critical stage of flight,” Mr Mitchell noted.

Shortly after the incident, National Jet Systems issued a notice reminding flight crews to consider supplemental oxygen use, and the declaration of a PAN in response to a cabin air quality event.

Then, in March 2024, the operator advised the ATSB of a number of additional safety actions, including training updates, a review of checklists, and the incorporation of learnings into the newly-introduced A220 aircraft’s smoke/fumes, hypoxia and incapacitation procedures.

“Airborne contaminants may result in the rapid onset of incapacitation, which although possibly subtle, can significantly affect the safety of flight,” Mr Mitchell said.

“Physical or cognitive incapacitation can occur for many reasons and may be difficult for others, or even the sufferer, to detect and respond to.

“As such, pilots should not hesitate to use supplemental oxygen.”

Read the final report: Flight crew incapacitation involving Boeing 717-200, VH-NXM, on approach to Hobart Airport, Tasmania on 6 June 2023

Publication Date: 16/04/2024

MTF...P2 

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RE: The search for investigative probity. - Peetwo - 06-08-2024

Chalk & Cheese: TSIB(S) vs ATSB

Via Accidents OS:

(05-25-2024, 08:53 AM)Peetwo Wrote:  Singapore Airlines Flight 321: Aviation accident and incident

There are many MSM and social media articles and news segments that have been running on the SQ Flight 321 CAT occurrence but IMO one of the more factual and less dramatised articles, is the following from Reuters:

Quote:

The mechanics of turbulence
What happened to Singapore Airlines flight SQ321 and why?

By Adolfo Arranz, Vijdan Mohammad Kawoosa, Sudev Kiyada, Han Huang, Mariano Zafra and Simon Scarr
Published May 23, 2024  04:30 AM GMT+10

Plus from blancoliro, via YouTube:

Hmm...wonder how long it took for the CAAS SSP to click into gear -    

SINGAPORE STATE SAFETY PROGRAM

I'd say it took the Singaporean aviation authorities, including the Transport Safety Investigation bureau, a matter of hours to kick into gear and then a  mere 8 days for a preliminary summary report to be published - WOW! 

Via Oz Aviation:

Quote:

PRELIMINARY REPORT RELEASED INTO TURBULENCE-HIT SINGAPORE FLIGHT
written by Jake Nelson | May 30, 2024

A preliminary report from Singapore’s Transport Safety Investigation Bureau (TSIB) has outlined the harrowing turbulence faced by passengers on Singapore Airlines flight SQ321.

43 passengers and crew were injured and an elderly British passenger suffered a fatal heart attack when the flight from London to Singapore hit severe turbulence last week, forcing it to divert to Bangkok. 56 Australians were on board, at least eight of whom were hospitalised.

The investigation team, comprising TSIB investigators working alongside US representatives from the National Transportation Safety Board (NTSB), Federal Aviation Administration (FAA) and Boeing, has pieced together the sequence of events based on data from the 777-300ER’s two black boxes.

According to the flight data recorder (FDR) and cockpit voice recorder (CVR), the flight began to experience a “slight vibration” at 07:49:21 (UTC) on 21 May, when it was passing over Myanmar at around 37,000 feet.

“Around the same time as the onset of the slight vibration, an uncommanded increase in aircraft altitude, reaching a peak of 37,362 ft, was recorded. In response to this uncommanded altitude increase, the autopilot pitched the aircraft downwards to descend back to the selected altitude of 37,000 ft,” the investigators wrote.

“In addition, the pilots observed an uncommanded increase in airspeed which they arrested by extending the speed brakes. While managing the airspeed, at 07:49:32 hr, it was heard that a pilot called out that the fasten seat belt sign had been switched on.”

The investigators believe that the increase in altitude was most likely due to an updraft, and that “the autopilot was engaged during this period”.

“At 07:49:40 hr, the aircraft experienced a rapid change in G as recorded vertical acceleration decreased from +ve 1.35G to negative (-ve) 1.5G, within 0.6 sec. This likely resulted in the occupants who were not belted up to become airborne,” they wrote.

 
Via the Singapore MOT website:

Quote:Transport Safety Investigation Bureau Preliminary Investigation Findings of Incident Involving SQ321
29 May 2024 - Press Releases

1.    The Transport Safety Investigation Bureau of Singapore (TSIB) has extracted the data stored in the flight data recorder (FDR) and cockpit voice recorder (CVR) of flight SQ321.

2.    The investigation team comprises TSIB investigators and United States representatives, from the National Transportation Safety Board (NTSB), Federal Aviation Administration (FAA) and Boeing.

3.    The investigation team has compiled a chronology of events based on preliminary analysis of the data from FDR and CVR:

a.    SQ321 departed London on 20 May 24 and the flight was normal prior to the turbulence event. At 07:49:21 hr (UTC) on 21 May 24, the aircraft was passing over the south of Myanmar at 37,000 ft and likely flying over an area of developing convective activity. The Gravitational force (G), recorded as vertical accelerations, fluctuated between positive (+ve) 0.44G and +ve 1.57G for a period of about 19 sec. (This would have caused the flight to begin to experience slight vibration).

b.    Around the same time as the onset of the slight vibration, an uncommanded increase in aircraft altitude, reaching a peak of 37,362 ft, was recorded. In response to this uncommanded altitude increase, the autopilot pitched the aircraft downwards to descend back to the selected altitude of 37,000 ft.  In addition, the pilots observed an uncommanded increase in airspeed which they arrested by extending the speed brakes. While managing the airspeed, at 07:49:32 hr, it was heard that a pilot called out that the fasten seat belt sign had been switched on.

c.    This uncommanded increase in aircraft altitude and airspeed mentioned in (b) are most likely due to the aircraft being acted upon by an updraft (the upward movement of air). The autopilot was engaged during this period.

d.    At 07:49:40 hr, the aircraft experienced a rapid change in G as recorded vertical acceleration decreased from +ve 1.35G to negative (-ve) 1.5G, within 0.6 sec. This likely resulted in the occupants who were not belted up to become airborne.

e.    At 07:49:41 hr, the vertical acceleration changed from -ve 1.5G to +ve 1.5G within 4 sec. This likely resulted in the occupants who were airborne to fall back down.

f.    The rapid changes in G over the 4.6 sec duration resulted in an altitude drop of 178 ft, from 37,362 ft to 37,184 ft. This sequence of events likely caused the injuries to the crew and passengers.

g.    In the midst of the sequence of rapid changes in G, recorded data indicated that the pilots initiated control inputs to stabilise the aircraft, disengaging the autopilot in this process. The pilots manually controlled the aircraft for 21 sec and reengaged the autopilot at 07:50:05 hr.

h.    The recorded vertical acceleration showed more gradual fluctuations over the next 24 sec, ranging from +ve 0.9G to +ve 1.1G, while the aircraft returned to 37,000 ft at 07:50:23 hr.

i.    After the pilots were informed by the cabin crew that there were injured passengers in the cabin, the decision was made to divert to Suvarnabhumi Airport, Bangkok, Thailand. On the way to Bangkok, the pilots requested for medical services to meet the aircraft on arrival.

j.    Approximately 17 minutes after the turbulence event, at 08:06:51 hr, the pilots initiated a normal, controlled descent from 37,000 ft and the aircraft reached 31,000 ft at 08:10:00 hr. The data showed that the aircraft did not encounter further severe turbulence during this diversion, and touched down in Suvarnabhumi Airport at 08:45:12 hr.

4.    Investigations are ongoing.

Compare that to this from Popinjay HQ..

From the ATSB's 'Occurrence category taxonomy and terminology' webpage the ATSB definition for an 'aircraft accident' (although recently updated - 1 Jan 2023???) still includes a provision for a serious injury:
 

Quote:A person suffers a fatal aircraft-related injury in relation to the operation of the aircraft; or

A person suffers a serious aircraft-related injury in relation to the operation of the aircraft;

This is the current ICAO Annex 13 definition:

Quote:An accident is defined as:

An occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down, in which:
a) a person is fatally or seriously injured as a result of:

• being in the aircraft, or
  
• direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or
  
• direct exposure to jet blast,
  

except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or..

Unfortunately there is a notified difference to the ICAO SARP definition for an accident:

Quote:"..Australia requires reporting of ‘transport
safety matters’, which, through definitions and
reporting requirements in the Transport Safety
Investigation Act 2003 and Transport Safety
Investigation Regulations 2003 result in
matters being reported which are equivalent to
those contained in the Annex 13 definition of
an accident.. The Annex 13 definition of an
accident is used for classifying reports in the
Accident Investigation Authority’s database.."

Not sure how that changes matters from a legal POV but IMO an occurrence involving a HCRPT aircraft, where a 'serious injury' has subsequently occurred due to that occurrence, should require the ATSB to define that event as an accident and therefore should necessarily precipitate an accident investigation within a matter of hours of being notified of the occurrence.
 
Therefore it is with interest I read the following Robyn Ironside article, via the Oz:

Quote:Turbulent Qantas flight under investigation after cabin crew member was badly hurt

May 31 2024

Qantas is being investigated over a turbulence episode on a flight from Sydney to Brisbane on May 4, in which a flight attendant suffered a broken ankle.

The Australian Transport Safety Bureau has only just flagged the investigation, almost four weeks after the incident which occurred on a Boeing 737-800 at about 9000ft.

It’s understood the decision to investigate was made after further information was gathered from Qantas.

According to the ATSB investigation brief, seatbelt signs were turned on but crew members were not yet seated when the turbulence struck.

“One of the cabin crew members sustained a serious ankle injury,” the ATSB said.

“The flight crew notified air traffic control and an ambulance crew was waiting for the aircraft on arrival.”

A Qantas spokeswoman said they were co-operating with the ATSB investigation.

“The aircraft experienced a brief, sudden turbulence event while descending into Brisbane,” said the spokeswoman.

“The seatbelt sign was on and all passengers were seated but cabin crew were in the process of taking their seats for landing when the turbulence event occurred.”

The injured flight attendant was treated on board by fellow crew members and an on-board medical professional.

“The aircraft landed normally in Brisbane and paramedics boarded the aircraft to attend to the injured crew member,” the spokeswoman said.

“We appreciate this may have been an unsettling experience for customers and we thank them for their co-operation.”

Witnesses and “involved parties” would be interviewed as part of the ATSB investigation, which was also expected to examine maintenance records and review recorded data.

A report was expected by the end of the year.

The investigation follows two episodes of severe turbulence on overseas flights, involving Singapore Airlines and Qatar Airways in the last week.

In the Singapore Airlines incident, one man died and scores of others were seriously injured when the Boeing 777-300ER experienced drastic fluctuations in vertical acceleration over Myanmar on May 21.

A preliminary report said the aircraft was approaching an area of developing bad weather at the time, and an updraft caused the sudden upward movement.



Days later, a Qatar Airways flight from Dublin to Doha struck unexpected turbulence over Turkey, causing injuries to 12 passengers and crew.

Eight of those were taken to hospital on arrival.

Despite the spate of turbulence-related events, there was no firm evidence to suggest turbulence episodes were becoming more severe or more frequent.

The ATSB’s own occurrence database showed only three turbulence events involving Australian aircraft had been reported in 2024.

A quick review of the ATSB AAI database webpage indicates the following:

Quote:

Summary

The ATSB is investigating a turbulence event involving Boeing 737, VH-VYK, being operated on flight QF520 from Sydney to Brisbane on 4 May 2024.

It was reported that as the aircraft was passing 9,000 ft on descent with the seatbelt sign on and cabin crew not yet seated, the aircraft encountered turbulence. One of the cabin crew members sustained a serious ankle injury. The flight crew notified ATC and an ambulance crew was waiting for the aircraft on arrival.

The evidence collection phase of the investigation will involve interviewing witnesses and involved parties, examination of maintenance records, retrieving and reviewing recorded data, and the collection of other relevant information.

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

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

This investigation is listed as an 'occurrence investigation' with a level of 'Short' and was initiated 3 weeks after the occurrence would have been mandatorily 'immediately' reported by Qantas - WTD?? 

Like CHALK and CHEESE? - Yep!   

MTF...P2 

PS: I note that there is no accompanying bollocks media statement accompanying this accident investigation - Err..I wonder why?? 

---

RE: The search for investigative probity. - Peetwo - 07-12-2024

Chalk & Cheese: ATSB v TSBC?? - 

Recently from PJ central media HQ, the man himself Popinjay popped in to give his profound wisdom and experience in Aviation Accident Investigation to be attributed to the following propaganda fluff piece on a 'Short' (sadly fatal -  ) preliminary report into a Chipmunk collision with terrain accident at YPJT on the 26 April 2024 (40 days in non-compliance with ICAO Annex 13 time limitations for a prelim report) -   :

Quote:Jandakot Chipmunk aircraft accident preliminary report

A preliminary report details evidence gathered to date by the ATSB from its ongoing investigation into an accident involving a Chipmunk aircraft at Perth’s Jandakot Airport on 26 April 2024.

ATSB investigators deployed to Jandakot after the DHC-1 Chipmunk, a former military pilot training aircraft, collided with the ground within the airport boundary shortly after take-off.

The pilot, who was the sole occupant, sustained fatal injuries in the accident.

Prior to the accident, the aircraft had been taxied by the pilot from Jandakot’s southern apron to the end of runway 24L, the report details.

“A witness on the southern apron took photographs of the aircraft taxiing past, and these show the latches on the left side engine cowl were oriented vertically,” Chief Commissioner Angus Mitchell said.

The Chipmunk’s left and right engine cowling doors are each secured by two latches. The latches fasten the doors when they are in the horizontal position, and the doors are unfastened when the latches are vertical.

After the pilot was given clearance, they began the take-off roll, and the aircraft became airborne about halfway along the runway.

“One witness recalled seeing something ‘flapping’ on the aircraft during the take-off,” Mr Mitchell explained.
That witness, and others in a nearby building, observed the aircraft roll to the left at low height near the end of runway 24L.

“Camera footage showed the aircraft’s angle of bank increasing and the aircraft descending into terrain. A camera about 180 m to the south-east of the accident site recorded the engine cowling on the left side opening and closing in the seconds prior to the accident.”

ATSB investigators’ wreckage examination noted damage to the engine cowl latches indicative of their being correctly fastened on the right side and unfastened on the left.

“All major aircraft components were accounted for, witnesses had not reported any change in engine sound prior to the accident, and the propeller showed evidence that the engine was running at impact,” Mr Mitchell said.

ATSB examination established continuity of the aircraft’s flight controls, and the flaps were assessed to have likely been in the retracted position at time of impact.

As the investigation progresses, the ATSB will conduct further examination of the aircraft components, review aircraft and pilot documentation, and analyse the aircraft’s flight path, and impact forces.

A final report, which will detail analysis and the ATSB’s findings, will be released at the conclusion of the investigation.

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

Read the preliminary report: Collision with terrain involving a Oficinas Gerais de Material Aeronautico DHC-1 MK 22 Chipmunk, VH-POR, at Jandakot Airport, Western Australia, on 26 April 2024

Publication Date
04/07/2024

Keep in mind this is only a prelim report into a relatively straight forward pilot error 'Short' investigation, so why does Popinjay feel the need to sign off on 'attributed' to him quotes that are pretty much taken directly from the prelim report?

EG:

PJ said: “A witness on the southern apron took photographs of the aircraft taxiing past, and these show the latches on the left side engine cowl were oriented vertically,”

Report said: ..A witness on the southern apron took photographs of the aircraft taxiing past, which show the engine cowl latches on the left side were oriented vertically..

PJ said: “One witness recalled seeing something ‘flapping’ on the aircraft during the take-off,”

Report said: One witness, located at the run-up bay, recalled seeing something ‘flapping’ on the aircraft during the take-off.

PJ said: “Camera footage showed the aircraft’s angle of bank increasing and the aircraft descending into terrain. A camera about 180 m to the south-east of the accident site recorded the engine cowling on the left side opening and closing in the seconds prior to the accident.”

Report said: ..The camera footage showed the aircraft’s angle of bank increasing and the aircraft descending before colliding with terrain. A camera at a building about 180 m to the south‑east of the accident site recorded the engine cowling on the left side opening and closing in the seconds prior to the aircraft’s collision with terrain (Figure 3)...

Now compare that waffle and regurgitated piffle; to the following TSBC Final Report into another pilot error terrain collision accident involving a flight training pilot on his 1st solo circuit in a C152:

Quote:Loss of control and collision with ground

Orizon Aviation Québec Inc.
Cessna 152, C-FNBP
Québec/Jean Lesage International Airport, Quebec
01 August 2023

View final report

The occurrence
On 01 August 2023, an Orizon Aviation Québec Inc. Cessna 152 aircraft was on a local training flight, with one pilot on board.

Upon landing at the Québec/Jean Lesage International Airport (CYQB), Quebec, the aircraft bounced and veered off the runway to the south, and then became airborne again. As the aircraft climbed, the left wing stalled, and the Cessna collided with the ground.

The pilot was seriously injured. There was no post-impact fire.

Media materials

News release

2024-07-04 - Investigation report: Loss of control and collision with ground at Québec/Jean Lesage International Airport in Québec, Quebec
Read the news release

(read the rest of the page - HERE.)

News media video footage:

 

This investigation took 11 months to complete and is defined as a class 4 investigation:

Quote:Class of investigation

This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.

This was the extent of the media blurb for this accident:

Quote:News release

Investigation report: Loss of control and collision with ground at Québec/Jean Lesage International Airport in Québec, Quebec

Dorval, Quebec, 4 July 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23Q0088) into the accident involving a Cessna 152 aircraft operated by Orizon Aviation Québec Inc. which occurred during a training flight at Québec/Jean Lesage International Airport in Québec, Quebec on 1 August 2023.

The TSB conducted a limited-scope, class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-360-4376
Email: media@tsb.gc.ca

Hmmm...spot the difference?? - 

MTF...P2 

---

RE: The search for investigative probity. - Peetwo - 07-13-2024

Popinjay's ATSB not investigating QF1 A380 July 7th hydraulic failure incident. -

AvHerald ref: https://avherald.com/h?article=51af7455

Via the Oz:

Quote:A380s built to withstand busted tyres say Qantas pilots after a dramatic landing in Singapore

An incident involving a Qantas A380 which burst three tyres on landing at Singapore after turning back with a hydraulics issue will not be investigated because it was handled well by crew.

After gathering further information from Qantas, the Australian Transport Safety Bureau decided an investigation was not warranted as it was “a technical issue appropriately managed by pilots”.

The flight to London was in the air for just over two hours in total, after pilots received an alert about a potential hydraulics issue shortly after takeoff from Singapore late Sunday night.

The decision was made to return to Singapore and conduct a heavy landing, with three of the superjumbo’s 22 tyres blowing out on impact.

After disembarking passengers, a Qantas employee delivered a short address to inform them what happened.

Passenger Andrew Sward who was relocating from Australia to London with his young family, said the communication from pilots during the flight and on landing was “quite transparent and well-managed”.

“I can’t really fault them for how they handled the situation,” said Mr Sward.

“They arranged for all passengers to be put up overnight in various hotels and then individual arrangements were made for replacement flights.”



A Qantas A380 pilot who did not want to be named said the aircraft was designed to taxi with as many as nine flat tyres and it was not considered a serious threat to safety.

“The tyres are filled with nitrogen because it’s incombustible and helps prevent a wheel fire,” said the pilot.

“They can withstand a maximum landing speed of 204 kts but they can deflate as a result of a high energy stop in a rejected takeoff situation or a heavy landing.”

Deflations, or tyre blowouts, were still considered quite rare with another A380 pilot saying he had not experienced one, other than in the simulator, in almost 16 years of flying.

Designed to withstand temperatures as high as 650 degrees Celsius on landing, A380 tyres were replaced in “every 60 or 70 landings”.

“So basically they’re replaced every month or so, they’re not like car tyres that last four or five years,” said the pilot.

The A380 involved in Sunday’s incident remained in Singapore awaiting inspection by engineers before returning to service.

As a result Qantas was forced to swap in other aircraft for the A380 registered VH-OQH — one of just six in operation currently as four underwent maintenance in Abu Dhabi.

Passengers on Sunday’s aborted flight to London were re-accommodated on other flights the next day.

A Qantas spokeswoman apologised to customers, and thanked them for their patience.

Qantas A380s carry up to 485 passengers.

Plus from Oz Aviation: QANTAS A380 TYRE BLOWOUT ‘APPROPRIATELY MANAGED’, SAYS ATSB

MTF...P2  

---

RE: The search for investigative probity. - Kharon - 07-14-2024

The mills of the gods grind slow; etc.

The truth contained within the rest of that line is questionable; much depends on just how 'fine' the end product is, and is it fit for purpose? The glib, rather slippery article from the ABC – HERE – exposes some fairly ugly facts; easily read and soon forgotten. Just another quick glance, head shake and back to the funny pages or the form guide. How can it be that the nation, particularly those who actually run the joint, just accept  the facts presented without the roof coming off the building. How?

“What I seek to accomplish is simply to serve with my feeble capacity truth and justice, at the risk of pleasing no one.”

To begin at the very end; there is a man dead, another seriously injured and a hull written off to scrap and salvage. The 'operation' whilst at a slightly elevated 'risk' level should, properly managed, been much less risk to life than the razor grass cuts, snake bites and cranky crocodiles, pissed off with nest invasion. It  begs a personal question; would I be the 'dope on the rope'? Probably not; but not because of any perceived 'aeronautical' risk. I don't like hot, sweaty condition, insect bites, razor grass, or even glorious mud; hate it all. But, in a tolerable environment; sure why not: BUT. I would want to see the scripted risk mitigation; the operations manual, the approvals and pilot qualification training program, recent flight check report and experience. Then a look at aircraft maintenance records, before checking out the aircraft myself – to be sure. It would be interesting to see if a 'sling load' qualification was valid. Then I would need to address such matters as airborne rappelling; and, possibly even fast rope from a helicopter. In short; there is a small mountain of 'safety' related maintenance, pilot and 'rope-man' training and qualifications which, even if not strictly 'mandatory' should be given some serious consideration and be, at least in part nodded to – risk acknowledged? . For example:-

Sling Endorsement.

“This rating is a requirement for helicopter pilots working in the areas of fire fighting, search and rescue, and mining and logging. Sling load operations are one of the most technically difficult skills to master and require a high level of concentration, so completing this training is guaranteed to increase your flying ability and career prospects. We have highly-experienced instructors available to train you for Long Line and Short Line Sling endorsements. Minimum flight time required for this rating is determined by your instructor and dependent on the time it takes you to become proficient in the operation.”

Or: Before 'rappelling' from a helicopter – see – HERE – and note the 'boxed' rider at the end of the blurb.

“A story has no beginning or end: arbitrarily one chooses that moment of experience from which to look back or from which to look ahead.”

The whole Crock o' Crap matter is now the subject of endless 'legal' wrangling; trained legal minds at 10 paces; banging away at each other, scoring high blown 'points'; blocking attack, defending their paying clients and so on and so forth. But will they ever get down in the weeds and trace this almost (99%) preventable death to the radical cause. The initial approvals issued by CASA and the ongoing monitoring of company adherence with those approvals. Were the maintenance logs checked against flight times; were the defects recorded and corrected; was there a rigid fuel policy? All good solid operational oversight stuff; - but what of the 'sub culture' : the company attitude toward real 'risk mitigation'. How many 'normalised deviance' items were investigated related to aircraft fitness for role? Clearly, no questions were ever raised; it was deemed to be an operation so squeaky clean that it was completely acceptable for the CASA Board to visit and toddle off for scenic flight. Ye gods, had the 'inspectors' been doing their jobs; in Broome and in the bush – perhaps (sans intent) this and other tragedies could have been prevented. Perhaps the whiff of police operations played a part; or not, just another intriguing 'curiosity' in this saga.

“Wise men have interpreted dreams, and the gods have laughed.”

Aye; there's blame 'aplenty to share around; but IMO, CASA failed in the beginning, failed in the middle and at the end are doing what they always do best – pass the responsibility off through legal verbiage and denial. Why not, they have all their get out of jail cards, neatly scripted and carefully tucked up their sleeves. Failed to perform design operational function, but brilliant in defense of the indefensible. Bloody marvelous...Stellar etc.....


Toot - toot.

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RE: The search for investigative probity. - Peetwo - 08-03-2024

Back to Ops Normal for Popinjay's concocted investigation Media Releases?? -  

Courtesy this week's DTS Stewie Macleod, via PJ's media minions:

Quote:E190 airliner’s high rate of descent highlights importance of monitoring autoflight system modes


An Embraer 190 airliner’s high rate of descent while on approach to Alice Springs reinforces the importance to flight crews of continuous attention to their aircraft’s selected autoflight system mode, an ATSB investigation report details.

On 24 August 2023, an Alliance Airlines-operated Embraer 190 was on a scheduled passenger flight from Darwin to Alice Springs with 63 passengers, 2 flight crew and 2 cabin crew on board.

Approaching Alice Springs Airport at about 10,000 ft, shortly after 4:15 pm local time, the flight crew, with the first officer as pilot flying and the captain as pilot monitoring, were advised by air traffic control to expect to overfly the airport before conducting a circuit to land on runway 12.

However, ATC subsequently offered a shortened straight-in visual approach.

At the crew’s request, they were cleared by ATC to track west as required, to allow for extra track miles to configure the aircraft (as it was at a higher altitude than it normally would be for that approach).

To expedite the aircraft’s descent, the flight crew initially extended the slats, flaps and speedbrakes to increase drag.
They also selected flight level change mode (FLCH) in the aircraft’s autoflight system (one of 11 modes that control the aircraft’s vertical flight path), to ensure the aircraft did not exceed the 210 kt speed requirement set by ATC.

They subsequently opted to further increase drag by extending the landing gear, despite the aircraft having sufficient track miles remaining to comfortably intercept a normal descent profile.

“FLCH mode controls the selected speed via pitch changes rather than thrust adjustments, so as the aircraft entered a turn with its gear down, it pitched nose down to maintain the selected speed, which increased the rate of descent significantly,” ATSB Director Transport Safety Stuart Macleod said.

Shortly after, and possibly influenced by a high workload, the pilot flying inadvertently changed the selected vertical control mode to flight path angle mode, where the aircraft maintains a set flight path angle to approach the selected altitude.

At this time, the captain was looking outside the aircraft, monitoring terrain clearance, and did not identify the changes in flight mode.

“Then the pilot flying did not identify the aircraft was starting to automatically capture the selected altitude, and selected a higher altitude, which disarmed the altitude select mode,” Mr Macleod explained.

“This resulted in the flight director resuming a high rate of descent close to terrain, which was not promptly identified by the pilot monitoring, due in part to their focus looking outside the aircraft.”

The crew’s attempts to arrest the descent were not immediately successful, and the aircraft descended within 1,800 ft of ground level, with a rate of descent above 3,000 ft/min.

“When the aircraft’s automation did not respond to flight crew inputs in the way they anticipated, the crew disconnected the autopilot and took manual control of the aircraft, landing without further incident,” Mr Macleod said.

“Flight crews’ continuous attention to the autoflight system mode as displayed on the primary flight display is critical to their situation awareness,” Mr Macleod noted.

“Further, this incident highlights the importance of flight crews continually monitoring descent profiles, irrespective of the type of approach being flown and the level of automation being used.”

Read the report: Flight management occurrence involving Embraer 190, VH-UYN, 20 km north-west of Alice Springs, Northern Territory, on 24 August 2023[/size]

Publication Date: 02/08/2024

(Note: This was (again) a 'Short' investigation, which according to PJ's notified difference to ICAO, didn't require a prelim report but still took 346 days to complete and therefore didn't require an annual interim update.) 

This extract and ICAO link from the report is IMO the best reference that industry readers should be referring to...

Quote:Safety message

This incident highlights how important continuous attention to the autoflight system modes displayed on the primary flight display is to situation awareness.

The ATSB reminds flight crews the importance of continually monitoring descent profiles, irrespective of the type of approach being flown and the level of automation being used.

An ICAO safety advisory on Mode Awareness and Energy State Management Aspects of Flight Deck Automation reminds pilots that if

they recognise they are uncertain about the autoflight modes or energy state, they should not allow the airplane to continue in an unstable or unpredictable flight path or energy state while attempting to correct the situation. Instead, pilots should revert to a better (usually lower) understood level or combination of automation until the aircraft resumes the desired flight path and/or airspeed. This may ultimately require that pilots turn off all automation systems and fly the aircraft manually

MTF...P2

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RE: The search for investigative probity. - Peetwo - 09-04-2024

Popinjay to the rescue on fatigued ATCOs?? -

Via PJ's media minions:

Quote:Fatigue management improvements underway after Brisbane Centre controller found asleep at end of their night shift


A Brisbane Centre air traffic controller who was found asleep at their workstation towards the end of their shift had worked multiple consecutive night shifts resulting in sleep debt, an ATSB investigation report details.

The approach controller, who was managing the Cairns Terminal Control Unit (TCU) within Airservices Australia’s Brisbane Air Traffic Services Centre (‘Brisbane Centre’) was found asleep at about 5:15 am on 9 December 2022. The oncoming approach controller found the night shift controller lying across 2 chairs with a blanket covering them. 
Several factors contributed to the controller failing asleep, the investigation found. 

“These included the time of day, the very low workload in their sector, a roster pattern with multiple consecutive night shifts, and the controller increasing their risk of falling asleep by lying across 2 chairs, not moving, and not undertaking activities to maintain mental alertness,” ATSB Chief Commissioner Angus Mitchell said.

“The controller had also been working multiple night shifts with reduced extended rest periods, which likely reduced their ability to obtain restorative sleep.”

When the controller was found asleep, there was no traffic in the Cairns TCU airspace, which was usual for that time of day, and there were no scheduled flights until after their shift.

However, had the controller been woken by a radio broadcast, they may have experienced ‘sleep inertia’, with the risk of delayed communications, or incorrect instructions/actions, and likely affecting their ability to manage any conflicts arising from traffic infringing their airspace without a clearance.

“There were no negative consequences from this occurrence, but it does highlight areas for improvement in work scheduling and fatigue risk management,” Mr Mitchell said.

The investigation also identified issues relating to Airservices Australia’s broader management of fatigue.
“An over-reliance on tactical changes to manage the roster at Airservices was likely due to an underlying lack of resources,” Mr Mitchell explained.

“As a result, cumulative fatigue was not being effectively managed strategically, and an over-reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.”

Following the incident, Airservices has increased its overall number of air traffic controllers, including in the North Queensland group.

The investigation also identified Airservices’ fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, but the tool’s effectiveness was limited as supervisors were not identifying low workload as a fatigue hazard.

Airservices has subsequently developed additional guidance and training on the fatigue risk assessment process, including information on how low traffic situations should be treated as high risk.

Separately, the Civil Aviation Safety Authority has recently introduced changes to air traffic service fatigue risk management system requirements. Airservices is working with CASA to trial its existing system against the new requirements, and is using feedback to make improvements.

“Fatigue remains one of the most relevant ongoing concerns for safe transport, despite increased awareness across the transport sector,” Mr Mitchell said.

“We urge transport operators to investigate fatigue events to identify and remedy deficiencies in work scheduling, fatigue risk management processes and risk controls.”

Read the report: Air traffic controller incapacitation, Brisbane, Queensland, on 9 December 2022

Publication Date: 03/09/2024

This investigation was apparently a defined investigation that took 1 year, 8 months and 26 days to complete. There was also 2 safety issues identified and bizarrely only published yesterday?

Quote:Fatigue risk management system

Safety issue number: AO-2022-065-SI-03

Safety issue description: Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Fatigue assessment of low workload

Safety issue number: AO-2022-065-SI-04

Safety issue description: Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard. 

 
Reading the basic timeline for these 'safety issues' it would appear that ASA was only made aware of the SIs in recent months:

Quote:Action description

On 16 June 2024, Airservices Australia advised the ASTB that:

Airservices Air Traffic System Fatigue Safety Assurance Group is currently working to review and develop additional guidance material, training or coaching sessions that will assist end users in the application of the FACT process. (Action FSAG/27) An understanding of the possible impact of low workload will be included as part of this action.
Additionally, Airservices Australia provided the ATSB with a copy of supporting documentation on 29 July 2024 and advised that it:

…will be published this week…[and]…provides clearer guidance regarding breaks and reiterates the information contained in the FACT guide regarding low traffic volume being high fatigue volume. A representative from the human performance team will attend a line leader meeting to provide advice on the use of FACT, fatigue, workload and break management advice.

While on the subject of the dubious performance of the Popinjay version of the ATSB, I noted I missed 2023-24 Supp Estimates AQON that is quite revealing and fills a number of gaps in the vacuous oversight/non-oversight of transport safety and it's associated alphabet agencies:

Quote:Senator Bridget McKenzie asked:

1. Chief Commissioner ’s review 2021–22 states that ATSB ‘flagged our ongoing concern about collisions between trading ships and small vessels on the Australian coast’ following an incident in February 2020. What additional actions have been taken to mitigate the risk of these collisions?

2. In 2021-22 the ATSB failed to meet the performance criterion that ‘85% of safety issues [are] addressed in the previous financial year’. Given that only 74% of safety issues were addressed in 2021-22, what needs to happen to meet this performance criterion?

3. In 2021-22 the ATSB missed its target median times to complete short (8 months), defined (16 months) and systemic (22 months) investigations. How can ATSB investigations be completed within the target times?

4. Despite a substantial increase in air traffic, the ATSB received approximately $500,000 less in government funding in 2021-22 compared to 2020-21. Did this impact the agency’s functions?

Answer:

1. There were three collisions between trading ships and small vessels between 2015 and 2018 and a further collision between a fishing boat and bulk carrier on 29 February 2020 (investigated by the Australian Transport Safety Bureau (ATSB) as MO-2020-001). That investigation (and others previously) highlighted the importance of maintaining an adequate look out and the value of surveillance technology to increase traffic awareness. The ATSB continues to monitor such occurrences and notes that there have not been any collisions related to inadequate look out over the last few years.

2. The ATSB is a ‘no-blame’ safety investigator and does not have any power to enforce the addressing of safety issues identified during ATSB investigations. However, the ATSB does work with safety issue owners to encourage appropriate safety actions, both during an investigation and afterwards. Some safety issues take time to address, especially when new regulations are involved. As such, safety issues will continue to be addressed in later years. For 2021-22 this particular measure was not met as a number of safety issues identified in that year rolled over into 2022-23 where they were addressed. This is reflected in the 2022-23 ATSB Annual report which shows that for the 2021-22 year, 85 per cent of safety issues had been addressed.

3. The ATSB has been actively targeting the performance of investigation times, and this is reflected in the 4-year decreasing median for Short and Defined investigations shown in the 2022-23 ATSB Annual Report. Measures in place are restricting the number of active investigations to an average of two per investigator, adherence to a project management approach to investigations, and an even distribution of investigations across three directors. In 2023, the ATSB strategic plan led to a dedicated Short investigation team (to conduct the majority of office-based short investigations), and a dedicated Data Recovery team, Safety Analysis and Research, Marine investigation team and Rail investigation team. While there will always be some variability in the length of investigations depending on complexity (especially the larger systemic investigations), the above measures are expected to continue to reduce the median time of investigations in the forthcoming years.

4. To ensure, as far as practicable, that the ATSB can resource the investigations it takes on, the ATSB limits the number of investigations to an average of two per investigator (although investigators work across multiple investigations). With the ATSB’s present resourcing this accommodates approximately 90 investigations a year across aviation, marine and rail. There are currently no budget measures associated with industry growth, however the Australian Government provided an additional $4.6 million in the 2023-24 Budget (in addition to its ordinary annual appropriation) to allow ATSB to retain a staffing base of 110 ASL and conduct safety investigations across all modes of transport within its remit. The Government has commissioned a Review of Operations and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies, announced in the 2023-24 Budget, which is expected to make recommendations to Government relating to agency resourcing.

 
"..Some safety issues take time to address, especially when new regulations are involved. As such, safety issues will continue to be addressed in later years. For 2021-22 this particular measure was not met as a number of safety issues identified in that year rolled over into 2022-23 where they were addressed..."

Hmm...I wonder if that's why PJ's crew don't actually notify the issuance of a safety issue till the day the final report is released, therefore delaying as long as possible the performance monitoring of the individual safety issue?

  "..the ATSB missed its target median times to complete short (8 months), defined (16 months) and systemic (22 months)..." investigations.

So this investigation overshot it's target median time by 2 months and 26 days, for what would appear to be a relatively straight forward operational control (IE FRMS deficiency) investigation - I wonder where the hold up was??  

MTF...P2 

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