The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Peetwo - 07-31-2015

Quote:
The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. The ATSB Commission urges the transport community to give heightened attention to the risk areas featured below. These are the areas where Australia’s aviation, rail and maritime communities can make safe transport systems even safer. 
SafetyWatch gives you information about each safety concern, strategies to help manage risk areas along with links to safety resources. 

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

Have your say at the Chief Commissioner's blog InFocus
Subscribe now to keep up-to-date with news from the ATSB or follow us @ATSBinfo on Twitter. 
 
Click on a photo for more information.

 


Related: SafetyWatch
 

Still working on joining the dots with all this and in the coming days we (PAIN) hope to post further findings & conclusions.

Needless to say it would seem from the evidence derived from many sections of the ATSB website (including the page above), that the ATSB Commission & Executive Management team, are simply delaying & obfuscating their promised proactive actions to the Minister, the Parliament & the travelling public. 

In the process this mob continues to bring the previous excellent reputation of the ATSB/BASI into ill repute, while the Chief Commissioner keeps thumbing his nose at the disturbing findings & excellent recommendations of the RRAT Senate Committee (PelAir inquiry), the TSBC & the Forsyth review, in some vain attempt to wait it out till public & industry scrutiny wanes.
Well I'm here to tell the CC, the Commission & the EMT, that is not going to happen...

Ok to the Safety Watch page (above) which I happen to think is an excellent initiative. However that is only if properly promoted, maintained & updated, sadly this does not appear to be happening.

In reference to the Ferryman post & Marty's list of contributory factors...

Quote:Contributing Factors


Contributing factors (not exhaustive) as outlined above include the following:

• The FMC waypoints and vertical altitude requirements were not correctly crosschecked by the crew.
  
• The Boeing 777’s FMC is restrictive when selecting visual arrivals. It doesn’t provide VNAV ‘enabled’ runway thresholds or the feature to extend a path from the crossing height.
  
• It’s possible that there wasn’t suitable awareness among crew on how the user created waypoints should be used to ensure a correct 3° path.
  
• After a 14 hour flight, it’s highly likely that all crew were fatigued and far more likely to make errors.
  
• The long haul crew are, likely any global long-haul crew, on the verge of being perpetually uncurrent. It may have been months since any of them had flown an approach to Melbourne’s RW34.
  
• Although automation shouldn’t be discouraged, it is expected that, consisted with any visual approach, crew should not be distracted from monitoring external references.
  
• The RW34 Victor arrival sets an early expectation for an initial high rate of descent.
  
• The crew made attempts to unsuccessfully resolve the automated high rate of descent with another form of automation (V/S, Vertical Speed) when disconnecting automatics might have been more prudent.
  
• The Boeing 777 FMC does not facilitate easy creation of waypoints off the runway threshold.
  
• The visual approach via SHEED (with the 2500 feet altitude requirement) is poorly designed and does not provide a 3° descent profile by default. No mention is made on the chart.
  
• No VSD is available for the Boeing 777. If it were installed, the error in the vertical profile would be easily identified.
  
• No call for a go-around (from any of the three monitoring crew) was made when the aircraft vacated company stabilised approach criteria (well below two dots low on the PAPI).
  

...there is I believe two broad safety concerns off the Safety Watch page relevant to the Virgin incident.

Each of the 'safety concerns' is accompanied by a Youtube video, see here:

1. Data input errors  
  
Handling approach to land

However I would argue that both of the above Safety Watch 'safety concerns', could automatically fall within a much broader & significant 'safety concern' and that is the 'breakdown of situational awareness'. In recent years there has been several high profile accidents where unrecovered 'breakdown of SA' has been a significant causal factor (e.g. Colgan Air Flight 3407, AF447, Asiana Airlines Flight 214).

The sad reality of the obfuscating actions/inactions, the subjective editing and the beyond Reason methodology is that Australia as a signatory to ICAO is no longer a proactive, healthy contributor to the worldwide improvement of aviation safety--- --

Anyway much MTF very soon...P2  

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RE: The search for investigative probity. - Gobbledock - 07-31-2015

P2;

"The sad reality of the obfuscating actions/inactions, the subjective editing and the beyond Reason methodology is that Australia as a signatory to ICAO is no longer a proactive, healthy contributor to the worldwide improvement of aviation safety"

Makes you wonder what the hell ICAO are thinking? Seems that they are just another obsfucating toothless entity big on talking but small on action. What a joke.

P.S As for that windsock picture P2, it is as flaccid as Beakers old fella. Just put a trough, beard brush or TV camera in front of him and watch it rise to full mast!!

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RE: The search for investigative probity. - Kharon - 08-05-2015

It is often said, a picture is worth a thousand words.



Ironic ain’t it; where a missing piece of the ATSB jigsaw is used to promote the ATSB ‘safety’ system, when the ATSB have hidden the piece away to prevent a true picture emerging.  Won’t bore you to death with the tedious research, blind alleys and dead ends P2 and I have been down, looking for the missing piece.  Actually it’s more than one piece, you will note that the piece shown is from the middle of a picture; the additional missing pieces are ‘corner’ pieces on which the frame is built.

Just focussing on Melbourne for a while; it is nearly impossible to accurately define ‘how many’ incidents (not quite accidents) have occurred with similar, ATSB defined, contributory factors.  But, if you take each of the mentioned factors and create a matrix with the major headings there are common threads binding the incidents. Take loss of situational awareness, then start adding up the number of incidents where this has been a factor.  It very quickly becomes a significant number; to refine the construct there needs to be a ‘study’ or discussion paper defining ‘why’ there is an increase in events where situational awareness has been significant.  Use the Rex v Coal Loading dock as a benchmark; the ATSB wrote it off to ‘illness’, dim light and other equally frivolous reasons.

FCOL – a Saab would have landed on the dock, with both aircrew chanting the pre landing checks; the gear was down and the aircraft configured for landing – 8 mile south of a bloody great big airfield, with all the toys and; thankfully, an alert crew in the control tower.  Loss of SA ? Certainly.  But was that all? No sir, it bloody well was not all.  

I’ll stop here, you can see where this is heading, there are at least 20 details which have not been examined let alone considered.  We could, between us probably draft a first class analysis and strip the incident right back to bare bones.  Hell we could probably even dream up some recommendations which would assist with rectification.  Could we make them stick – no way.  Just a bunch of tendentious bloggers, to be ignored with impunity by that master of air accident investigators.

Handing over P2 – your call, it’s an interesting study but to complete it through to conclusion will take many, many long, unpaid hours to get there, with no hope of changing anything.  Forsyth had no luck, the Senators had even less.

Is the game worth the candle?

Toot toot.....

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RE: The search for investigative probity. - P7_TOM - 08-05-2015

You know boys; you could, as Pel-Air did, provide a positive proof analysis of the potential areas which will, in time, produce Australia’s first major incident.

You will also be in the box seat for the ‘we told you so’ prize.  

Will that change anything – even after the event.  In short NO.  The problem, IMO, lays within the structure of the system.  Join CASA = instant expert.  Work for ATSB = my way or the highway or live with your good work reduced to a ploy involving which version of ICAO Annexe 13 was in play at the time.  Don’t believe Senator Fawcett has forgotten that one, do you? Or you could invoke the ASA and reveal the problems their approach to airspace management provides for our ATC and the aircrew who suffer daily to manage the requirements of system which was and remains based on the DC3 (little bit of poetic licence there; but you get my drift).  

In short, have a beer, some well earned time with the family, leave it alone.  Nothing, bar a major hull and life loss will have any impact; and, “we warned you” that a combination of government approved factors will, eventually, combine to create a major event will be of little satisfaction.

Can we prevent this?  Yes, if we move swiftly and positively.  Will that happen? No, the  history of real change and the mystique is against you.

The BRB will be having a dedicated session on the Reluctance to Change (RTC) ethos, where, to protect rice bowls, the government agencies will and do, go to extraordinary lengths, to convince Ministers, the public and the aviation world that they; and, they alone are the experts. Which is a total bollocks.

MTF – Oh you bet.

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RE: The search for investigative probity. - thorn bird - 08-08-2015

I agree P7, could I be forgiven for believing the Mount Erabus disaster was the catalyst that sent New Zealand on its true reform project. I understand that before that they were just like CAsA, spawned from the military, imbibed with military arrogance and ego's, hell bent on bringing their aviation industry to its knees.
Well just look at it now, amazing what true reform can do.

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RE: The search for investigative probity. - Gobbledock - 08-08-2015

Herr Thorny;

"I agree P7, could I be forgiven for believing the Mount Erabus disaster was the catalyst that sent New Zealand on its true reform project. I understand that before that they were just like CAsA, spawned from the military, imbibed with military arrogance and ego's, hell bent on bringing their aviation industry to its knees.
Well just look at it now, amazing what true reform can do"

And with Erebus you had the following factors - a shonky Government of the day protecting it's major airline at any cost, a lethargic, useless and outdated aviation authority, and a useless imbecilic crooked safety investigative bureau. Hmmm, must be tautology, I am sure I've seen this somewhere more recently? Yes in NZ they had all these factors wrapped up in one little parcel with a smoking hole ribbon on top!! 
Far too many good people died unnecessarily on top of Erebus that day (R.I.P), and not enough of the shysters who contributed to this accident paid a fair price (however over the subsequent years the Ferryman has made several house calls and put in many miles crossing the River Styx to complete his post Erebus mission).

So while the Dolans of the world jet off to France, the Truss's of the world attend Mary Poopins stage shows, the CAsA Wodgers of the world protect the guilty while persecuting the innocent and the ICAO of the world is staffed by silver haired bureaucrat retiree's who have a penchant for eating cucumber sandwiches while indulging in talk wankfests, our countdown clock slowly but surely ticks ever closer to it's version of aviation midnight - a giant smoking hole or midair fireball.

We've said it a thousand times Miniscule and we will say it a thousand more;

TICK TOCK

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RE: The search for investigative probity. - Kharon - 09-10-2015

Road Kill.

When Beaker recovers from being thrown under the bus by An(g)us and Hoody, he may like to contemplate a piece offered by Ben Sandilands – HERE – on Plane Talking. Or, maybe this one which has been ignored by both Beaker and Sandilands. _HERE_ 

Quote:The ATSB has tweeted its media followers that the definition of a serious aviation incident is one in which an accident nearly occurred.

That means that it classed the Qantas too low approach to Melbourne Airport by an A330 in 2013 as an incident that could have ended in the crash of a 300 seat airliner on the Sydney-Melbourne route

The search for Investigative Probity continues with out a map or candle; with NX trying to strike a spark to kindle the flames while Beaker pisses on the flint.  

MTF?– watch this space.

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RE: The search for investigative probity. - Peetwo - 09-10-2015

(09-10-2015, 08:58 AM)kharon Wrote:  Road Kill.

When Beaker recovers from being thrown under the bus by An(g)us and Hoody, he may like to contemplate a piece offered by Ben Sandilands – HERE – on Plane Talking. Or, maybe this one which has been ignored by both Beaker and Sandilands. _HERE_ 

Quote:The ATSB has tweeted its media followers that the definition of a serious aviation incident is one in which an accident nearly occurred.

That means that it classed the Qantas too low approach to Melbourne Airport by an A330 in 2013 as an incident that could have ended in the crash of a 300 seat airliner on the Sydney-Melbourne route

The search for Investigative Probity continues with out a map or candle; with NX trying to strike a spark to kindle the flames while Beaker pisses on the flint.  

MTF?– watch this space.

ATSB BASR - Risk mitigation vs topcover?? 

Was kind of wondering when someone would mention this 'serious incident' & the strange disconnection with the one 'serious incident' (AO-2013-047) & one 'not so serious incident' (AO-2013-130)... - Why? Well because the correlation between those two aviation safety occurrences (especially the Virgin incident) and the ATLAS 747 'incident' is IMO quite remarkable:

Quote:Introduction


During approach into Melbourne Airport, Victoria on 9 September 2012, the Boeing 747 aircraft descended below the minimum permitted altitude for the final segment of a standard arrival route (STAR) prior to landing at Melbourne. A number of factors influenced this descent and are discussed in the following analysis.

The approach

The flight crew were initially issued with the STAR clearance involving a visual final segment by air traffic control (ATC) after they requested an approach to runway 34 instead of runway 27. During the descent, and prior to commencing the STAR, the flight crew requested an area navigation global navigation satellite system (RNAV GNSS) approach. ATC advised that this approach was not available unless it was an operational requirement. The captain related a concern about the prevailing visibility, to which ATC responded that the visibility should improve as they neared the airport. In response the flight crew decided to continue with the STAR and visual approach.

During this approach, ATC issued the clearance ‘from SHEED, cleared visual approach’. However the crew did not read back the full clearance, omitting the ‘from SHEED’ condition issued by ATC. This condition only allowed them to commence the visual approach once they passed the SHEED waypoint. The clearance was provided at the same time that the crew sighted the lead-in strobe lights, for which they had been actively searching to assist their turn onto final. It also occurred close to the point where a missed approach procedure would be required had the lights not been sighted. It is possible that the activity of searching for the lights, particularly in the reported hazy conditions, and the preparation for a potential missed approach drew the crew’s attention away from monitoring their vertical position on the approach.

Additionally, as the flight crew were United States (US)-certificated, they were used to the normal practice in US airspace of STAR clearances being cancelled implicitly by the provision of new clearances. In Australian airspace, an aircraft remains on a STAR until ATC transmits ‘Cancel STAR’ and provides further instructions, or until the aircraft reaches the end of the published STAR procedure. While the captain had flown into Australia ‘many times’ previously, this was the first time in Australian airspace for the first officer.

The first officer reported believing that any restrictions associated with a STAR no longer applied once cleared for a visual approach.

The flight crew’s shared mental model of the ability to descend on receipt of a new clearance (in this case for the visual approach) was inconsistent with that of the air traffic controller. The controller was not expecting the flight crew to descend below the minimum height before passing the SHEED waypoint, as stipulated in the STAR procedure. While the flight crew’s understanding was consistent with the procedures used in US airspace, these did not apply in Australia, leading to the descent below the minimum permitted altitude.

Air traffic control clearance procedures

The standard risk mitigation for ensuring that a clearance was understood by flight crews was for the flight crew to read back the clearance to the controller and for the controller to correct any errors. The flight crew’s read back of the clearance for the visual approach to runway 34 from the SHEED waypoint was incomplete. The controller did not detect the omission and the crew’s misunderstanding of the visual approach clearance remained undetected by the flight crew. Consequently, the flight crew followed their understanding of the clearance as it applied in the US, and descended below the cleared minimum of 2,500 ft before the SHEED waypoint.

If the controller had recognised and challenged the incomplete read back, it is likely that the flight crew would have been alerted to the need to maintain 2,500 ft until passing SHEED.

Approach design and approval

The design of the LIZZI FIVE RWY 34 VICTOR ARRIVAL necessitated a descent profile of 3.5° for the visual approach from SHEED to the runway 34 threshold. A review of exceedances at SHEED by other operators highlighted that this increased angle resulted in higher descent rates, often in excess of 1,000 ft/min. This is the recommended maximum rate of descent for a stabilised approach. A higher descent rate increases the likelihood of an unstable approach during the descent from overhead the SHEED waypoint.

During the approach, the aircraft was descended to about 1,900 ft over the SHEED waypoint, which was about 600 ft below the minimum altitude at that position. A review of similar occurrence events found that other aircraft had also overflown SHEED at about this altitude. This lower altitude was consistent with a 3° descent profile for a landing on runway 34 and with the first officer’s recollection of commencing a 3° descent profile once they believed they were cleared to descend.

There were a number of control practices restrictions in the Manual of Air Traffic Services (MATS) in relation to ATC issuing STAR clearances with a visual segment to foreign operators of heavy or super jet aircraft. These restrictions would have precluded this aircraft from conducting a STAR with a visual segment at other locations in Australia.

However, MATS allowed the SHEED visual approach by foreign operators if they were familiar with its conduct, and this operator was considered to meet this requirement.

Aside from an undocumented local control procedure for application to the SHEED visual approach by foreign operators of heavy or super jet aircraft, there were no alternative or additional defences to support this variation in control practice. In addition, the local control procedure required the flight crew to stop descending before SHEED, report sighting the lead-in strobe lights and then recommence the descent once the aircraft had passed SHEED. This resulted in the foreign crews conducting a step-down descent profile.

While this sequential clearance was a considered decision by ATC in order to minimise the risk of foreign flight crew misinterpreting the approach or descending prior to SHEED, it negated the inherent protections of a constant angle descent profile. The importance of constant-angle approaches was highlighted by the Flight Safety Foundation in their Approach and Landing Accident Reduction Tool Kit as a defence against unstable approaches and controlled flight into terrain.

 
The first paragraph under 'Approach design and approval' in bold is a critical part of the causal chain for this incident & the Virgin incident, because by a flawed design this approach introduces a stepped descent (duck'n'dive) sector (not below 2500' till past SHEED) which by design does not always meet the criteria for a stabilised approach (not > 1000' ROD). A standard (by the way) which is widely accepted and adhered to in approach design by most ICAO signatory States Worldwide.

Other glaring aberrations/observations with this investigation & final report.

1) The final report took just shy of three years to complete? - UFB...

2) So the ATSB investigators made the link/safety issue with the approach design (above). However the ATSB initially neglected to see the significance of this safety issue and subsequently did not promulgate a 'safety recommendation' or even a 'safety issue' until recently (i.e. nearly three years after the incident - AO-2012-120-SI-02)

Quote:Safety issue description

The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.

Proactive Action

Action organisation:
Civil Aviation Safety Authority
Action number:
AO-2012-120-NSA-051
Date:
01 September 2015
Action status:
Released

In response to this safety issue, the Civil Aviation safety Authority (CASA) advised that:

CASA acknowledges the Safety Issue identified by the ATSB in relation to the descent profile of the LIZZI FIVE RWY 34 VICTOR ARRIVAL. 3.5 is at the upper limit specified in Procedures for Air Navigation Services – Operations (PANS-OPS) Volume II for instrument flight procedures designed for Category D aircraft (including the Boeing 747). CASA intends to engage with Airservices to ensure the procedure meets instrument procedure design and ‘flyability’ standards.

 
3) There was also a safety issue sent to Airservices - AO-2012-120-SI-01  In light of the Virgin incident nearly a year later I find the ASA disconnection & proactive action quite bizarre...

Quote:Safety issue description

Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.

Proactive Action
Action organisation:
Airservices Australia
Action number:
AO-2012-120-NSA-050
Date:
01 September 2015
Action status:
Released

In response to this safety issue, Airservices Australia (Airservices) advised of the following proactive safety action:

Airservices agrees with the safety issue identified in the report. Airservices has commenced action to remove the MATS [Manual of Air Traffic Services] provision which allows the use of SHEED visual segment for all International Heavy and Super Heavy aircraft, rather than just Australian and New Zealand operators as detailed in MOS [Manual of Standards] Part 172. The related operational documentation will be reviewed and amended accordingly in line with our standard safety change management process.

Airservices will aim to introduce the permanent change to the November 2015 MATS [Manual of Air Traffic Services] update and will issue a temporary local instruction in the interim. Airservices will advise the ATSB when the action has been completed.

 So again we have a situation where a latent safety risk, that could have been effectively mitigated back in 2012, is only now (3yrs later) being properly addressed - again UFB..

Next "K" said:

Quote:..The search for Investigative Probity continues with out a map or candle; with NX trying to strike a spark to kindle the flames while Beaker pisses on the flint...  

This was in reference to last night's special Senate ASA inquiry hearing and relevant to Farmer Joe's discovery that the ATSB website has no record of the 05 July YMML LAHSO BOS ''serious incident' - More Beaker Bullocks.

{Comment:From the  above we get further confirmation from Hoody that the ATSB indicated they would be investigating this serious incident- so where is the record... }


MTF?- You bet..P2  

 
  

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RE: The search for investigative probity. - Kharon - 09-11-2015

Top post, nicely done P2; it is not a tale that will intrigue or delight the punter, not until they are crispy critters, strewn across the Essendon paddocks.  The alarming thing is the way each agency is passing the buck.  Three years of SFA done about the situation; we don’t know who to bless or who to blame and the parcel is being passed about so fast, that even when the music stops, and there is one of those long, embarrassed silences, a pregnant pause, the parcel never stops.  Too hot to handle?  Nah, stroll in the park for the spin doctors and word weasels.

The list of deferred, delayed and obfuscated reports is reaching critical mass.  It’s all very well to say – “Not our problem” or beg off with “not enough resources”; that’s a bollocks added to a fairy story.  Hiding behind ‘legally’ tight definitions of what must be and what need not be done is becoming passé.  The list from the last 12 months is awaiting the Beaker editing, the list from the past 24 months is awaiting retrospective ‘in-put’ before arriving on the commissioners desk for selective editing; the list going back three years is slowly maturing, almost ready for release.

Time the great healer – or amnesia assistant.  Lets face it, the 747 incident is lost in the mists of time (and the annals Beaker special edition web site), the SHEED approach is, mathematically at least, a potential killer.  The real amount of ‘incidents’ and ‘unstable’ approaches is unknown; a can of worms which no one, not ASA, not CASA nor the ATSB will touch.  Maybe it’s as safe as houses, but who would know.  

Only one thing can be factually demonstrated, there is a perceived problem, one which has existed for many years and no one has even bothered to investigate; even if just to say – No, it’s as sound as a bell; Why? Well you silly boy, if anything goes awry and the blame game parcel is passed about nobody will stand and say ‘we declared it safe and here’s our supporting evidence.

Seems as though there’s a run on old Niccolò Machiavelli today:-

Quote:“Occasionally words must serve to veil the facts. But let this happen in such a way that no one become aware of it; or, if it should be noticed, excuses must be at hand to be produced immediately.”...Machiavelli.

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RE: The search for investigative probity. - Gobbledock - 09-15-2015

Virgin Australia automated flight system investigation

It should only take Beakers boys about 2 years to investigate this one.
Poor Tid-bin-dildo, the wait will be painful.

https://www.atsb.gov.au/publications/investigation_reports/2015/aair/ao-2015-107.aspx

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RE: The search for investigative probity. - Kharon - 09-29-2015

Ben Sandilands Blog, Plane Talking, published on Crikey pays close attention to the ATSB ‘reports’ on incidents and accidents.  There exists yet another PC report from the ATSB – HERE – the ATSB ‘report’ dribbles off into some soft, fluffy conclusions which rely, heavily, on the Jetstar solution and fix.  Now I don’t have the slightest doubt that the J* team will sort it out; I have even less doubt that a lesson has been learned.  Nothing but praise and faith in the J* check and training system.  However there are two outstanding matters which ATSB have failed to address:-

A clinical analysis which confirms; absolutely, that the J* ‘fix’ is a correct one and that every precaution to prevent a reoccurrence has been employed.  

Secondly, and, IMO most importantly ATSB have failed miserably to ‘extrude’ the analysis to the point where a basic, reoccurring killer has not been acknowledged.  Who FFS was flying the aircraft, monitoring the flight path and speed?  Two pilots and a Vref – 20 deficit and a go around from an ‘unstable’ approach.  Kids stuff.

Who’s on first, Watts on second and nobody watching the clocks – too damn busy reading from the QRH.   It’s an approach to land, not a bloody book fair.

I’d back J* to do the right thing – if only someone would get back to basics.  Fly the ducking aircraft within the rules of a ‘sterile’ environment, the way it is supposed to be.

Arrgghhh – FCOL,

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RE: The search for investigative probity. - Peetwo - 09-30-2015

(09-29-2015, 06:08 PM)kharon Wrote:  However there are two outstanding matters which ATSB have failed to address:-

A clinical analysis which confirms; absolutely, that the J* ‘fix’ is a correct one and that every precaution to prevent a reoccurrence has been employed.  

Secondly, and, IMO most importantly ATSB have failed miserably to ‘extrude’ the analysis to the point where a basic, reoccurring killer has not been acknowledged.  Who FFS was flying the aircraft, monitoring the flight path and speed?  Two pilots and a Vref – 20 deficit and a go around from an ‘unstable’ approach.  Kids stuff.

Who’s on first, Watts on second and nobody watching the clocks – too damn busy reading from the QRH.   It’s an approach to land, not a bloody book fair.

I’d back J* to do the right thing – if only someone would get back to basics.  Fly the ducking aircraft within the rules of a ‘sterile’ environment, the way it is supposed to be.

Arrgghhh – FCOL,

Well said "K"..   Sounding like a broken record, yet again we get a wet lettuce, PC'ed report that has taken more than 2 yrs (27 months) to create and still has no positive risk mitigation benefit for any other industry stakeholders.

Must of been a slow aviation news day because surprisingly MMSM avguru Creepy has covered this story not once but twice in < 24hrs?? - Jetstar pilots let plane drop below minimum approach speed

&..

Quote:Jetstar pilots distracted while training forced to abort landing  

• by: STEVE CREEDY
  
• From: The Australian
  
• September 30, 2015 12:00AM
  

Aviation Editor
Sydney


Pilots distracted by a training ­exercise allowed their Jetstar aircraft landing at Sydney Airport to drop below the minimum ­approach speed and prompted automatic systems to abort the landing, an Australian Transport Safety Bureau report has found.  

The Airbus A320 was conducting an instrument landing system approach in mid-2013 using the aircraft’s automatic landing function when the training captain disconnected the auto­thrust system and pulled back the thrust levers to idle.

He asked the first officer to ­assess the effect of his actions on the proposed approach and, after consulting a quick reference handbook, the crew extended the landing gear and flaps and finalised the re-landing checklist.

While they were discussing the exercise, the airspeed dropped to below the minimum approach speed. The captain was in the process of applying thrust when the ­aircraft’s alpha-floor protection system, which automatically increases thrust if the plane slows too much, activated.

“Take-off/go-around thrust was automatic­ally commanded by this system and the flight crew conducted a missed approach,’’ the report said.

It found the pilots were distracted by the training exercise and failed to notice the airspeed approaching the minimum. Minimum and decision heights entered into the autoflight system as part of the training exercise were also not appropriate for landing.

“The resulting increased workload impacted on the first ­officer’s capacity to effectively fulfil the pilot monitoring role,’’ the report said. “As a result … Jetstar issued a memo to its check and training pilots highlighting the requirements for autoland training. The memo reiterated that flight crew must only use the minima for the approach being flown.’’

The air safety investigator urged training pilots to recognise experience and capability and ­ensure a training exercise never compromised the primary task of monitoring and flying a plane.

 
Strange because except for this pic here from the 1st version..



Distracted Jetstar pilots allowed their plane (not this one) to drop below its minimum approach speed. Source: News Corp Australia
..& maybe one or two words there is no additional information in the 2nd version...

Anyway after reading the ATSB report & Ben's article, besides the crew dynamic (cockpit gradient) & the fact this was a training exercise, I can see some disturbing parallels to the Jetstar approach to Singapore incident in 2010 - AO-2010-035.  Which was also reviewed by Ben after the final report was released yet again nearly 2yrs after the event:

Quote:Jetstar pilot mobile txting stuff up uncovered in ATSB inquiry

Ben Sandilands | Apr 19, 2012 12:59PM |

Updated with Jetstar statement in full

The ATSB has given an insight into the failed state of flight safety standards in Jetstar that saw phone txting distract a captain to the extent that a landing at Singapore in 2010 had to be aborted at very low altitude.

It concerns the conduct of a flight from Darwin to Singapore on 27 May 2010 in an Airbus A321 which could have been configured with close to 220 seats.

Using a re-enactment of the flight in a Jetstar flight simulator, the ATSB found that during the descent to Changi Airport there was a two minute period between about 2800 feet and 1000 feet “where no control manipulations or systems activation was recorded.”

It says “In contrast, during that period, a number of tasks should have normally been completed in preparation for landing, including:

• selecting the landing gear down
  
• selecting the flaps to ‘Config 3’ and then ‘full’
  
• arming the ground spoilers
  
• selecting auto brake
  
• completing the landing checklist, and
  
• checking the flight parameters
  
  

The report also finds that the captain, who was the pilot-not-flying, but required to oversee the performance of the first officer who had assumed that role, had left his mobile phone on after leaving Darwin, and that when it came within range of a Singapore mobile network, began to download various messages.

“Somewhere between 2,500 ft and 2,000 ft in the descent, the crew heard noises associated with incoming text messages on the captain’s mobile phone. The first officer requested that a missed approach altitude of 5,000 ft be set into the Flight Control Unit (FCU) and, after not getting a response from the captain, repeated the request.

“The FO recalled that, after still not getting a response from the captain, he looked over and, on seeing the captain preoccupied with his mobile phone, set the missed approach altitude himself.

“The captain stated that he was in the process of unlocking and turning off his mobile phone at that time and did not hear the call for the missed approach altitude to be set in the FCU.“
 At this point the first officer says he heard an alarm indicating the jet had descended below 1000 feet .

 “The FO indicated that at this point, it was his usual practice to perform a visual scan of the cockpit instrumentation. He further stated that he felt ‘something was not quite right’ but could not identify what it was.

“The captain reported that he did notice that the landing gear was still up and that the flaps were at ‘Config 2’.

“He also stated that he was not maintaining a focus on the stable approach criteria as he was the Pilot Not Flying (comment: which is an appalling admission.) Neither crew member initiated the landing checklist.”

The next section of the ATSB report reads like one of those 1960s inquiries into a British charter airline crash in terms of general cluelessness or lack of focus in the cockpit.
“At 720 ft radio altitude reading, a master warning and associated continuous triple chime for ‘Landing Gear Configuration’ activated. The FO stated that, on hearing that warning, he noted a red light in the landing gear lever and an ECAM message ‘LG not DN’ displayed on the E/WD. In combination, that signified that the landing gear had not been selected down.

“At about 650 ft RADALT, or 4.5 seconds after the commencement of the master warning chime, the landing gear was selected down. At 503 ft RADALT, or about 7 seconds after the landing gear was selected down, a ‘Config 3’ selection was made by the crew. The captain stated that he ‘instinctively’ reached out and selected gear down and ‘Config 3’ upon hearing the master warning.

“The FO reported feeling ‘confused’ by the captain’s action, as he was preparing to conduct a go-around. Neither the captain nor the FO communicated their intentions at that time.

“Eleven seconds after the landing gear was selected down, a ‘Too Low Gear’ Enhanced Ground Proximity Warning System (EGPWS) alarm sounded. That signified that the aircraft had descended below 500 ft RADALT with the landing gear still not secured in the down position (the landing gear was still in transit to the down position at that time).”

Think about the situation. A Jetstar flight with up to 220 or more passengers on board, is low over the ground at Changi Airport, its wheels up until the last moment, and its flaps incorrectly set for a landing, while a person behaving like a moron in charge of jet airliner is so absorbed in his phone he is unaware of the dangerous situation that he has allowed to occur.

His first officer can’t even get his attention. This is an Australian flag carrier, about which, if the report is to be believed CASA did diddly squat possibly because it might just be totally cravenly gutless when it comes to looking out for passenger welfare in anything owned by or flown by Qantas.

I don’t care what CASA does in the background. Can we please see it do it in the foreground?

A full nine seconds after the ground proximity warning triggered the flight crew commenced a go-around.

“The FO made the standard ‘go around flap’ call and selected Take Off/Go-Around power on the thrust levers, initiating an automated go-round procedure. The recorded data showed an initial pitch-up command, consistent with the commencement of the go-around, at 392 ft.

Both crew stated that they were unaware of the minimum height reached before the aircraft climbed, but believed that they initiated the go‑around just below 800 ft RADALT.”

The jet landed safety after the go-around, and after a discussion about fatigue and other matters both pilots then operated the return service to Darwin.

This is an astonishing report in that it details a failure of safety standards in Jetstar that ought to have caused action by CASA, the Civil Aviation Safety Authority, the some body that exhibited such courage, diligence and concern in relation to Tiger Airways, yet is totally, utterly missing from this document.

The ATSB discharged its duty to detail the safety relevant events in detail,  and however makes this astonishing cop-out observation near both the start and finish of the report, which anyone interested in their safety on Jetstar services should download and read in full.

It said: “The investigation did not identify any organisational or systemic issues that might adversely impact the future safety of aviation operations. However, following this occurrence, the aircraft operator proactively reviewed its procedures and made a number of amendments to its training regime and other enhancements to its operation.”

Note the word “future”. The conduct of this particular flight was incompetent, and reflects on the safety of flight obligations of Jetstar, and calls into serious doubt the oversight the board of Qantas and the senior management of its subsidiary Jetstar are required by law to exercise in relation to safety outcomes in the low cost carrier.

Jestar has responded to the ATSB report as follows:

Quote:JETSTAR STATEMENT ON JQ57 REPORT
19 April 2012

Jetstar is using an incident involving cockpit distraction on one of its flights as part of its regular training for pilots.

On 27 May 2010, JQ57 from Darwin to Singapore cancelled its initial approach into Changi Airport because pilots detected the aircraft was not fully configured for landing by the time it reached 500ft. The aircraft, an A321, landed safely and without incident shortly afterwards.

These cancelled landings – called ‘go arounds’ – are standard procedure for all airlines and happen every day at airports around the world.

A report released today by the Australian Transport Safety Bureau into JQ57 showed that the pilots – both highly experienced and with a combined total of 17,000 flying hours – became distracted by a combination of factors. This distraction led to the pilots’ deciding to perform a go-around.

The ATSB report made no findings against Jetstar, nor did it find any fault with Jetstar’s policies or procedures. The safety of the aircraft was never compromised.

Jetstar’s Chief Pilot, Captain Mark Rindfleish, said: “We take a very conservative approach to how far before touchdown an aircraft should be completely configured for landing. In the case of JQ57, pilot distraction meant all the landing checklist items weren’t completed before the aircraft passed an altitude of 500 feet, at which point a go-around was required under our operating procedures.

“Human factors, like distraction, are why airlines have so many procedural safeguards built into how they fly. The combination of factors on JQ57 has provided new learnings and the opportunity to add to these safeguards, which we take very seriously.”
As well as making JQ57 a case study in its training on the potential for cockpit distraction, Jetstar has also:

*    Added an item to the takeoff checklist providing a reminder to pilots to ensure their mobile phones are switched off. This is a result of the investigation finding one of the pilot’s phones was inadvertently left on and automatically picked up messages on approach to Changi Airport, adding to distraction in the cockpit.
*    Increased the mandatory distance for the landing checklist to be completed from 500ft above the airport to 1,000ft as an additional safeguard.
*    Through training, reinforced the importance of crew ensuring they use mandatory rest periods in between duties effectively.

 
Fast forward > 3yrs &..A320 full of SLF on approach to YSSY and Sociopath TNG Capt with "gotcha" training exercise on short final??

Err no comment..



MTF..P2


     

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RE: The search for investigative probity. - Gobbledock - 09-30-2015

Fast forward > 3yrs &..A320 full of SLF on approach to YSSY and Sociopath TNG Capt with "gotcha" training exercise on short final??

Call me a cynic but possibly root cause was not fully identified in the first incident, no proper mitigation implemented and no later review undertaken to ensure the loop was closed. Fast forward to the second incident similar in nature, with Captain Insano pulling a stupid stunt that should've been reserved for the SIM. Of course, yet again, the ATSB produces a wet lettuce leaf response and with absolutely no doubt CAsA will do nothing because we are talking about Qango.

Let's see, 2 serious incidents which are more or less past and present. But things happen in three's so what does the future hold? Probably more foolish antics. We've had flight deck texting and we've had flight deck 'BOO' surprises so perhaps the next incident will be one of the Crew on short finals tuning in to listen to Riverfire in Brisbane, or taking photos of a beautiful sunset, or maybe Captain Insano putting a salad sandwich together on his lap while the F/O fills in the form guide. Then......pancake.....a pavement sandwich whilst a panicked regulator, investigator and Miniscule department  head into lockdown while they work out who will be the next John the Baptist!

"Disturbing skies for all"

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RE: The search for investigative probity. - thorn bird - 09-30-2015

Oh dear, I fear that smoking hole is approaching at an ever accelerating rate.
A minister asleep at the wheel, a naive amateur directing the ship, with a half dozen
or so "Experts" scrabbling to wisper in his ear!!
"Forgive them father for they know not what they do"

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RE: The search for investigative probity. - Gobbledock - 09-30-2015

Thorny;

A minister asleep at the wheel

I would prefer him to be asleep in 1A when the first biggie bites the Tarmac!

Just sayin........

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RE: The search for investigative probity. - Kharon - 10-01-2015

Only my own opinion; a notion or ramble may be a more fitting description -  but the deep, systematic flaws in the ‘training’ programs seem to be appearing on a regular basis.  We have quite a long list from the last couple of years; Mildura, Mooranbah, Melbourne, Sydney, etc.  Newcastle being the exemplar where the crew were rescued from landing on the coal loading dock by an alert ATCO.  

My mind keeps picking at what I can only call – ‘disconnection’.  The modern aircraft, particularly the Airbus are so ‘automated’ that it is quite possible for the crew to feel ‘remote’ from the operational reality.  When you have a control column’ in one hand and the power levers in the other, the aircraft is ‘with you’, firmly between your feet on the rudder pedals.  The flight path, profile and speed – controlled by you.  Reality.   It is quite a surreal experience to be playing with automatic systems, remotely asking a computer to sort out the task at hand.  Is it possible that crew are becoming more focussed on the ‘keyboard’ and connected to the computer; rather than cognisant of the external factors?  It’s academic; but clearly something is going wrong, regularly, and if the ATSB can’t or won’t provide a solution, we need to examine the basic tenets.  

Then there is the simulator syndrome; in the ‘sim’ the event being discussed here could have been stopped; a discussion held while the ‘aircraft’ patiently waited at 1000 feet until the point of the exercise was understood; then, reversed back to where the initial problem occurred and- it’s off to the races, problem solved.  Is this ‘attitude’ endemic? the reality of a 50 ton aircraft at 135 KIAS on final approach is that it will not patiently park at 1000’ while the mysteries are unravelled, it’s real. It’s dynamic and it is no place for a crew to be disconnected  from the task at hand.  

Please note; not knocking or denigrating anyone or anything; just trying (struggling)  to understand the radical causes.  Thinking out loud if you like.

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RE: The search for investigative probity. - Peetwo - 10-07-2015

(10-01-2015, 06:50 AM)kharon Wrote:  Only my own opinion; a notion or ramble may be a more fitting description -  but the deep, systematic flaws in the ‘training’ programs seem to be appearing on a regular basis.  We have quite a long list from the last couple of years; Mildura, Mooranbah, Melbourne, Sydney, etc.  Newcastle being the exemplar where the crew were rescued from landing on the coal loading dock by an alert ATCO.  

My mind keeps picking at what I can only call – ‘disconnection’.  The modern aircraft, particularly the Airbus are so ‘automated’ that it is quite possible for the crew to feel ‘remote’ from the operational reality.  When you have a control column’ in one hand and the power levers in the other, the aircraft is ‘with you’, firmly between your feet on the rudder pedals.  The flight path, profile and speed – controlled by you.  Reality.   It is quite a surreal experience to be playing with automatic systems, remotely asking a computer to sort out the task at hand.  Is it possible that crew are becoming more focussed on the ‘keyboard’ and connected to the computer; rather than cognisant of the external factors?  It’s academic; but clearly something is going wrong, regularly, and if the ATSB can’t or won’t provide a solution, we need to examine the basic tenets.  

Then there is the simulator syndrome; in the ‘sim’ the event being discussed here could have been stopped; a discussion held while the ‘aircraft’ patiently waited at 1000 feet until the point of the exercise was understood; then, reversed back to where the initial problem occurred and- it’s off to the races, problem solved.  Is this ‘attitude’ endemic? the reality of a 50 ton aircraft at 135 KIAS on final approach is that it will not patiently park at 1000’ while the mysteries are unravelled, it’s real. It’s dynamic and it is no place for a crew to be disconnected  from the task at hand.  

Please note; not knocking or denigrating anyone or anything; just trying (struggling)  to understand the radical causes.  Thinking out loud if you like.

To begin excellent thought provoking post by the Ferryman..

 'Disconnection' is indeed the key word here and it is not solely in the cockpit where this 'disconnection' is occurring. The investigator - & to a certain extent the regulator - seems to be failing to join the dots, although maybe there is a light at the end of the tunnel..

Moving on from the Sydney Jetstar approach dust-up incident and back to more familiar ground with Melbourne approach incidents...  

Noticed that the ATSB today have just released their latest Bulletin of aviation short investigations - Issue 43.

Hidden in the SIB - within the Jet aircraft section - there was this incident - Flight below minimum altitude involving a Boeing 777, A6-ECO, near Melbourne Airport, Vic on 18 July 2014 

Okay this is where we see the disconnection start to creep in with all those other Melbourne approach incidents. Quote from the summary page:

Quote:..As the aircraft approached BUNKY, air traffic control (ATC) cleared the crew to descend to 4,000 ft, and cleared the crew for the RNAV-U (RNP) runway 16 approach. ATC radar data shows that the aircraft overflew BUNKY at 5,000 ft, then continued descent, passing through 4,000 ft about 5 NM prior to BOL. Descent then continued, leading to an ATC Minimum Safe Altitude Warning alert as the aircraft descended through about 3,400 ft, about 4 NM prior to BOL. ATC questioned the crew about their altitude, and advised them that the relevant radar lowest safe altitude was 3,200 ft. Moments later the aircraft passed over BOL at about 3,000 ft and maintained that altitude until intercepting the vertical profile of the RNAV-U (RNP) runway 16 approach. The approach continued for an uneventful landing...

However this is where the disconnection becomes suddenly recoverable, because the international operator is strangely  forthcoming with the findings of their own internal investigation.
Summary continuing:

Quote:..The operator’s investigation found that descent below the 4,000 ft altitude restriction at BOL occurred because the crew programmed the Flight Management Computer (FMC) to overfly BOL at a ‘hard altitude’ of 3,000 ft. The operator’s investigation found that the potential for deviation below the 4,000 ft minimum altitude restriction at BOL was increased by factors related to aeronautical charts and the FMC navigation database...

To which the ATSB (without Exec PC interference) were able to make the following solid conclusions - Hoorah!

Quote:..For operators, this incident highlights the need for careful attention to FMC navigation data management, particularly any procedures that relate to crew modification of navigation data. Operators should remain mindful that any manipulation of FMC navigation data by flight crew has the potential to introduce errors. Additionally, operators are encouraged to work closely with aeronautical information service providers to ensure that aeronautical charts (and any other operational information) are presented in a manner that minimises ambiguity and reduces the potential for misinterpretation. For flight crew, this incident highlights the need for careful attention to approach procedure documentation and FMC navigation data management..

This was followed on in the full report by these active inputs from DIPs, that systematically identifies the holes in the cheese (again without any Exec PC editing)(warning - P2 actually recommends that the CASA Officers get a choc frog for their input to the following.. ):

Quote:Review of the factors identified in the investigation


The operator’s investigation found that descent below the 4,000 ft altitude restriction at BOL occurred because the crew selected the ‘hard altitude’ of 3,000 ft for BOL. The potential for deviation below the 4,000 ft minimum altitude restriction at BOL was increased by factors related to aeronautical charts and the FMC navigation database. Some of these factors are discussed in the following paragraphs.

The ATSB obtained comments and responses from involved parties including:

• the United Arab Emirates General Civil Aviation Authority on behalf of Emirates Airlines
  
• Airservices Australia
  
• the Civil Aviation Safety Authority (CASA).
  

The RNP approach had been designed by GE Naverus (Naverus), based on information in the Airservices Australia Aeronautical Information Package (AIP). The charts and FMC data used by Emirates were supplied by LIDO. LIDO developed the charts and database based on information in the Airservices AIP.
Procedure design – level depiction on the ARBEY STAR
No minimum altitude was specified at BOL on the ARBEY FOUR STAR.

Operator comments
Within the STAR, BOL had a coded speed restriction of a maximum 185 kt for approaches to runway 16, but did not specify a minimum crossing altitude. This allowed arrivals from other directions to cross BOL at a minimum altitude of 3,000 ft, instead of 4,000 ft as required via ARBEY. This conditional altitude restriction was specified in the approach charts only and not on the STAR chart. This procedure design did not protect the MEA of 3,400 ft on the arrival segment from position BUNKY to position BOL by a 'hard procedural altitude'. BOL is located at a distance of 11.6 NM from runway 16 and a crossing altitude of 4,000 ft would permit a constant approach angle crossing BOL on a 3.0° vertical descent path. Based on this, a lower crossing altitude (3,000 ft) for other arrival directions does not seem necessary.

The operator suggested that Airservices Australia consider procedural amendments to specify a minimum crossing altitude over BOL (of 4,000 ft or above) for all approaches and within the STAR design. This would protect against descents below MEA (and outside controlled airspace) within the arrival segment from BUNKY to BOL. It would also satisfy the requirement of Airservices Australia to be able to specify higher crossing altitudes (above 4,000 ft) for traffic separation. If Airservices Australia, as the State AIP, changed the procedure design, the various chart providers would then amend their corresponding FMC/FMS databases as well as the STAR and instrument approach charts.

CASA comments
CASA suggested a possible solution would be to include the altitude restriction in the STAR chart. This would then make the altitude obvious on the text and plan view, and the altitude restriction would be coded in the FMS. They also found that the overall complexity of the STAR chart did not aid pilots’ awareness.

Airservices response
In controlled airspace, the approach procedures are designed to keep aircraft 500 ft above the control area steps. The 4,000 ft minimum altitude was designed to keep aircraft in controlled airspace prior to BOL, rather than for terrain clearance.

Airservices further commented that a minimum altitude of 4,000 ft was not depicted on the STAR chart at BOL, as BOL was also applicable to the runway 27 arrival. This allows ATC to assign a higher altitude at that point for a runway 27 arrival due to potential runway 34 departures. No altitudes are depicted because two (or more) levels would be required to cater for the different runways. Only one level is permitted to be depicted against a waypoint (for a STAR) to avoid potential confusion as per Section 1-1-22 of Airservices 'Departure, Arrival and Air Route Management Design Rules' manual (ATS-MAN-0010).

Altitude requirements are not always specified on a STAR chart, and ATC is generally responsible for deciding whether altitudes are to be included or not. This occurs in the procedure design phase. When they are not included on the chart, ATC assigns individual altitudes to aircraft in order to facilitate vertical separation between them and assure terrain clearance.

   
This led to the following safety action & safety message statement:

Quote:Safety action


Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Aircraft operator

Crew awareness of restrictions on STAR
Soon after the occurrence, the aircraft operator published a company Notice to Airmen (NOTAM) for crew awareness. The NOTAM pointed out that approaches into Melbourne may include altitude restrictions that depend on the particular STAR being flown. The NOTAM also pointed out that some altitude restrictions may be depicted on the approach chart plan view only, and not necessarily on the relevant STAR chart, or the approach chart profile view. The NOTAM advised crews to exercise caution when reviewing STAR and approach procedures to ensure that all applicable altitude restrictions were observed.

Flight crew operations manual
The operator intends to reconsider Flight Crew Operations Manual guidance dealing with the benefits of changing initial approach fix ‘at or above’ altitude restrictions to hard altitudes, and discuss the depiction of altitude restrictions on the relevant charts with the chart provider.

Flight management computer coding
The operator has identified the FMC coding issue as a threat in their Hazard Identification and Risk Assessment statements. All new destinations and also, within the review cycle, existing destinations, will be checked against this threat and corrective action will be taken if applicable.

Airservices and CASA
CASA and Airservices intend to discuss the coding of the FMC at the next international instrument procedures panel, where an ‘integration’ subgroup includes FMC coding specialists. The aim of the discussion is to ensure the charts are used in the cockpit the way they are intended.

Safety message

For operators, this incident highlights the need for careful attention to FMC navigation data management, particularly any procedures that relate to crew modification of navigation data. Operators should remain mindful that any manipulation of FMC navigation data by flight crew has the potential to introduce errors. Additionally, operators are encouraged to work closely with aeronautical information service providers to ensure that aeronautical charts (and any other operational information) are presented in a manner that minimises ambiguity and reduces the potential for misinterpretation.
For flight crew, this incident highlights the need for careful attention to approach procedure documentation and FMC navigation data management.

For producers and providers of aeronautical information products, a guiding principle specified in Procedures for Air Navigation Services, Aircraft Operations is to keep all charts as simple as possible. This may assist in reducing flight crew workload and the risk of error, and coding issues when entering data into flight management systems.

What a difference in outcome when compared to final reports for the Virgin & Qantas Melbourne approach incidents (back a couple of pages from about here). More is the pity that the positive lessons learnt will not be disseminated across a greater worldwide industry/stakeholder audience because the report is basically buried in a ATSB short investigation bulletin..FCOL

MTF..P2

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RE: The search for investigative probity. - Gobbledock - 10-07-2015

"What a difference in outcome when compared to final reports for the Virgin & Qantas Melbourne approach incidents".

Now I seriously don't want to bring down the tone of the last posts with negativity, but......isn't it interesting how the ATsB's writing style, seriousness, even robustness in its report is more solid when dealing with an international operator? But when it comes to Australia's protected Rat as well as the almost equally protected Virgin the reports are softer, no knockout punches, just wet lettuce leaf slaps.

Hmmm so are we getting to the root cause of the ATsB - capture??

As you would say P2, MTF.

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RE: The search for investigative probity. - Kharon - 10-07-2015

Root or Roo-ted?

Quote:GD – “Hmmm so are we getting to the root cause of the ATsB - capture??”

The Melbourne charts (plates) have been and are becoming a bloody nightmare, buggers muddle.  Without local knowledge and familiarity the chances of ‘cockpit thrombosis’ occurring are greatly increased.  Those plates and the names and the transitions really do need some help.  But enough negativity.

No matter how it was produced; no matter who did the heavy lifting, irrespective of where ATSB ‘tucked’ the report, what matters is good catch P2.  Open a new box of Choc frogs, one for the airline for first class risk analysis and management, one for the ATSB for finally producing a ‘useful’ report and; last, but not least, finally (Halle bloody lujah) - one to CASA for jolly good work.

How very, very nice to award choc frogs to all for a job well done.  Duck it, I’m so pleased they can all have two – apiece; just for making me feel as though there is yet hope for the white hats.  Good job, well done, much appreciated and – thank you.


 ...  ...  ...  ...  ....

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RE: The search for investigative probity. - Peetwo - 10-20-2015

Bearded Buffoon read the riot act?

(08-27-2015, 06:10 PM)kharon Wrote:  Way I heard it was as part of the $25,999 package, Beaker was to take scuba lessons, so as to save the tax payer money.  The notion was that if he could overcome aqua phobia, then the retrieval of CVR gear from reasonable depths could be done in a ‘cost effective’ but safe, ICAO compliant manner.  Not to mention front page photo’s of Beaker with a half peeled wet suit, clutching a six year old relic could be plastered all over ‘le’ monde’ and other salubrious publications.  Win – win and the girls would love it – Butch Beaker.

In reference to the "K" post off the Horse-pooh thread it was noted in Senate Estimates last night that yesterday the ATSB had - in the normal BBB cynical, no fanfare, 'up yours' style  - updated the PelAir reinvestigation, with details (finally) of the CVR/FDR recovery tender:

Quote:Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009

 
Investigation number: AO-2009-072
Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  

Update
Updated: 19 October 2015
On 12 June 2015, the ATSB released a Request for Tender for provision of services for the recovery of the flight recorders from VH-NGA. After an extensive evaluation process in accordance with federal government requirements, a successful tender was selected and the ATSB has entered into a contract for a recovery operation to commence on site between 3 and 8 November 2015. The recovery operation is expected to be complete by the middle of November. A further update will be released after examination of the recorders at the ATSB’s technical facilities in Canberra and assessment of whether they contain recoverable and usable data.

The previous update on 25 May 2015 outlined the nature of the other investigation activities being undertaken by the re-opened investigation. These activities are close to being completed. In addition, the re-opened investigation has conducted interviews with both flight crew and both medical crew from the accident flight.

The investigation team are now in the process of analysing the available information and they have commenced the preparation of a draft report. Given the delay in recovering the recorders and the amount of information that has been collected and analysed, it is expected that a draft report will be released to directly involved parties for comment in early 2016.

   
However if the Bearded Buffoon thought that would be enough to placate the good Senators - in particular NX & DF..  - then I am afraid he was sorely mistaken..   
That, coupled with what the Heff called the "..MH370  stuff up''..

 

..& the line of questioning coming down the pipe from the Senators on MH370 (in particular Senator Gallacher )...


...gives the impression that BBB is in potential terminal trouble & could be the first in the MH370 scapegoat line-up to be pushed in front of the bus..

The trouble is we have seen Beaker survive from similar scathing criticism before. However if I was a betting man I'd say Murky & co have already got the box measured...

Update: Hansard now released in full - Rural and Regional Affairs and Transport Legislation Committee - 19/10/2015 - Estimates - INFRASTRUCTURE AND REGIONAL DEVELOPMENT PORTFOLIO - Australian Transport Safety Bureau


MTF...P2

    

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