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

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RE: Closing the safety loop - Coroners, ATSB & CASA - P7_TOM - 08-28-2022

But - Can we blame the weather man?

Or, is it us these days who are simply not weather aware?

Way back in time, as part of the DoE scheme (award) Fell walking morphed into rock climbing, which progressed (quite naturally) to mountains. We nearly always had access to a sailing dingy and as time went by, the odd motorcycle excursion was in order - saved heaps on train fare to the foreigners mountains - QED. It became a religion of a sort to watch the weather patterns: we knew all the sea (fishing) areas mentioned in the BBC broadcasts to 'those at sea' and got to be quite good at avoiding getting trapped up a cliff face or out in the dingy when the weather was liquid, lousy and Brass monkeys. Just lucky I guess.  This self education spoon fed the hunger and interest in the science and mystique of aviation weather analysis. This was aided and abetted by the 'Met Man' in the briefing office; who, no matter where you pulled up, was always willing to expand, explain and assist with what to reasonably expect in flight and at destination. Fascinating. 

I don't know if today's computer generated forecasts are any better or worse than the 'old' style - the percentage 'chance' based on recorded data is mathematically probably accurate; but it lacks the 'penetration' of a Met officer who mentions "keep an eye on the temperature down there; gets below 16c then these things will change - ". It made us all very 'aware' that things could, and often did not go quite to script. To pay 'attention' and to not worry too much about being 'legal' but operationally able and to make informed decisions against 'their' experience; rather than our own limited, small experience version.

There was another element which should be mentioned - the instructing pilots. Nav 1 - head down, flat out juggling the plan, map, prayer wheel, pencil and pen and aircraft (which refused to stay on height and heading when needed) - (and smiling - a lot) came the question - 'what if' and a weather scenario was sketched - "what ya gonna do"? Struggle for answer and blurt out half baked response (off heading already) "Ah yes" says this worthy - "but if that happens the route you have nominated will be worse than than this; because" - explanation followed. Nav 2 - forewarned, chat with the Met man - alternate plan formulated, noted on the back of the plan - ready to go. "That's more like it' says my worthy - "but what about XYX". Still on height and heading the discussion continued - just long enough for me to miss a reporting point. And so it went on - Such are the trials and tribulation of the neophyte. In later years, those discussions with Met man and instructor kept me not only out of harms way (mostly) but built an 'active' defence mechanism which served very well indeed, for the most part.

Don't us aged folk take a while to get to the point - but, that's why we are now aged, hoping booze and bad living don't carry us off. But, say you fly the same routes day in day out; after a while, you get to know the wrinkles; when there will be traffic; when there's a wind change which is the best approach and best shot at getting in; how to weigh your knowledge of local conditions against the soulless Met report; when to push, when to cry off; routine for line flying. Nevertheless; anything with which you are not 'familiar'  is just like driving in a strange city for the first time, even with the navigation system helping - you are still a little 'at sea' until the local traps and tricks are known. Same - same with random cross country flying - you simply don't know what you don't know. Grabbing a quick downloaded forecast and then just hoping for the best, without expecting the worst is a fools errand. Remember; always; Murphy is no mans friend.

Yus, my boy; I will have another. Cheers and thank you.....

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 09-01-2022

Coroner distrust and ATSB disconnect with investigation AO-2018-078 -   

As we begin to try and join the dots-n-dashes to yet another (IMO) cocked up (vs covered up) ATSB investigation, let us 1st consider the only (refer HERE) MoU agreement between the ATSB and an Australian State or Territory Coroner's office/jurisdiction: https://www.atsb.gov.au/media/48048/tas_coroner.pdf 

Quote:2 PURPOSE

2.1 The purpose of this MoU is to maximi se the effectivene ss of both parties
in carrying out their respective roles in the event of a fatal transport safety
accident by:

(a) recognising the similarity of goals of the Bureau and Coroners in
improving the safety of the public while at the same time
acknowledging the different methods used by the parties to achieve
those goals; and
(b) minimising unnecessary duplication of effort and the potential for
conflict without compromising the independence and function of
either party and to encourage a spirit of consultation and
cooperation directed to ensure both parties are able to carry out a
proper investigation.

2.2 The Bureau and Coroners acknowledge that this MoU cannot legally
restrict the statutory discretion and powers of either party under relevant
legislation.

2.3 It is not the intention of the parties to this MoU to create any legal
obligations between them as to the matters set out in it.

As far as I can gather, this 18 year old MoU represents the only such agreement between a Coroner and the ATSB still in force today?? Which brings me to the next point of interest, which perhaps helps to explain why the TAS Coroner dumped so heavily on the ATSB in his inquest report into the death of Nikita Walker - 

The following is a link to a report that involved the same operator, from the same Coroner, into another fatal aviation accident that occurred in 2014: https://www.magistratescourt.tas.gov.au/__data/assets/pdf_file/0004/388246/Langford,_Samuel_Peter_and_Jones,_Timothy_Peter.pdf

Quote:Comments and Recommendations:

I extend my appreciation to investigating officer, Senior Constable Michael Barber, for his investigation and report.
The circumstances of both deaths are not such as to require me to make any recommendations pursuant to Section 28 of the Coroners Act 1995.

The ATSB investigators were provided, at my direction, with every assistance by Tasmania Police investigating this tragic accident.

The subsequent decision by the ATSB to refuse my request for copies of witness statements obtained in the course of its investigation was, in such circumstances, both surprising and disappointing. The ATSB made the obvious point in its reasons for refusal that “ATSB investigations and [C]oronial investigations/Inquests [sic] fulfil separate statutory functions”. However, the common, and crucially important, statutory function of both the ATSB and the Coroner is the investigation of fatalities with a view, inter alia, to endeavouring where possible to prevent avoidable deaths occurring in similar circumstances in the future. The ATSB acknowledged as much.

The coronial investigation of the deaths of Mr Langford and Mr Jones proceeded on the basis that it was unnecessary to interview witnesses that had already been interviewed by the ATSB because it was understood, wrongly it would appear, that the ATSB would provide copies of those statements to the Coronial Division. The request for the statements was made after the ATSB had concluded its investigation and after it had released its report publicly.

In refusing to provide the requested statements the ATSB relied upon section 60 of the Transport Safety Investigation Act 2003 (Cth). That section prohibits the provision of restricted information. The expression ‘witness statement’ is included in the definition of that term. However, the prohibition is subject to section 60(5) which empowers the ATSB to issue a certificate authorising the release of witness statements where the ‘disclosure of the information is not likely to interfere with any investigation’.

Despite this provision the ATSB still refused the request, when there was no rational impediment, at all, to the provision of the requested statements and its investigation was complete.

In concluding I convey my sincere condolences to the family and loved ones of Samuel Langford and Timothy Jones.

Dated 21 July 2017 at Hobart in the State of Tasmania.

Simon Cooper Coroner

            
Hmm...it would seem to me that Coroner Cooper had duly respected the terms and conditions of the MoU and expected that same respect would be forth coming from the ATSB and yet that clearly did not occur. Then with his next dealings with the ATSB he found the same disrespect and dodgy disconnect, subsequently (inappropriately or not?) he vented his displeasure in his Nikita Walker inquest report -      

Next I make the following OBS from the AO-2018-078 report: 

(From under 'Bureau of Meteorology' - 'Forecasts', note the parts in bold)

Quote:A Bureau of Meteorology (BoM) graphical area forecast was issued at 0342 and was valid for the period 0400 to 1000, encompassing the accident flight. The forecast was applicable for all of Tasmania. The BoM reported that the forecast included mist (visibility reduced to 2,000 m) and broken[6] stratus cloud with a base of 200 ft above mean sea level (AMSL) for areas within 20 NM (37 km) of the coast (encompassing the Bathurst Harbour ALA),[7] associated with the low‑level moist onshore flow. The forecast also included areas of scattered light rain (visibility reduced to 7,000 m) throughout the entire area from a layer of broken altocumulus/altostratus cloud at 9,000 ft, and scattered stratus cloud between 500 ft and 1,000 ft. The forecast indicated that severe turbulence below 8,000 ft and widespread sea fog was expected.

The subsequent graphical area forecast issued at 0348 and valid from 1000 to 1600 was divided into two regions and showed a deterioration in the conditions in the south-west. Broken cumulus and stratocumulus cloud was between 2,000 ft and 8,000 ft, and visibility reduced to 7,000 m in scattered light rain.

The search and rescue helicopter pilot advised that the forecast on the day:

…was quite unusual (I have not seen one like it to date) which had broad brushed the entire state. This made me wonder if there was a technological issue behind it…

As a result, the pilot contacted the BoM who advised that the:

forecast for the South West region was poor, as the weather would be pushing inland from the south west and there was a high probability of low cloud but they could not quantify an accurate cloud base.

The closest aerodrome forecasts[8] (TAF) were available at Strahan (about 145 km north-west of the accident site) and Hobart (about 100 km east-north-east of the accident site).

The TAF for Hobart, issued at 0405, indicated 8 kt winds from the west and CAVOK [9] conditions, with a 30 per cent probability of deteriorations of less than 30 minutes due to thunderstorms and rain until 0900. From this time, the TAF indicated a change to the prevailing weather conditions, with a reduction in visibility, and increasing rain and cloud. 

The Strahan TAF was issued at 1737 (the day before the accident) and indicated that the conditions were deteriorating at 0300 the next day. The cloud base was broken stratus cloud with a base at 500 ft. It was subsequently updated at 0005 showing a deterioration at 0400, with broken stratus cloud with a base of 200 ft. A special report of the meteorological conditions at Strahan, issued at 0800 and 0830 on 8 December 2018, indicated that there was overcast cloud at 1,300 ft above ground level (AGL). At 0900, the cloud had deteriorated to include broken cloud at 600 ft.

Analysis of the conditions

There were no recorded observations of the conditions at the location of the accident. The BoM provided the following analysis based on satellite imagery, forecasts, and observations. Specifically, they noted that:

On the night of 7 December 2018, Tasmania was under a very moist north-easterly airstream, with dew point temperatures in excess of sea surface temperature thus sea fog, coastal mist and very low cloud were expected to develop around the coastal areas of Tasmania. A surface trough moving over the southwest in the morning of 8 December 2018 was expected to extend low cloud over southern Tasmania during the morning.

The satellite images showed that there was an ‘extensive layer of middle and high cloud associated with the passage of the trough’. Similarly, high-resolution images also indicated the presence of low-level cloud in the area, including the accident location (Figure 4).

Figure 4: Visible satellite image at 0800 showing the approximate accident location



Source: Bureau of Meteorology, annotated by the ATSB

The aerological diagram from Hobart indicated ‘a likelihood that cloud would form via orographic ascent[10] on the windward side of ranges’. Likewise, the relative humidity at other nearby locations was also high during the morning.

The nearest cloud and visibility observation sites to the accident location were at Hobart (100 km to the north-east) and Strahan Airports. However, Strahan Airport was considered to be more representative of the onshore flow at the accident site in the wake of the trough. Between 0345 and 0840, the cloud base at Strahan was between 1,000 ft and 2,000 ft. After this time, the cloud base lowered to below 1,000 ft, before gradually lifting later in the day. In addition, there were several instances where the visibility reduced to below 5,000 m during the night and morning, likely associated with areas of mist.

In summary, the BoM concluded that:

Conditions on the morning of 8 December 2018 were characterised by coastal sea fog and mist, low orographic cloud developing and the passage of a mid-level cloud band with light rain and virga.[11]

The relevant forecasts were consistent with the weather conditions in the area of the incident.

 
(Also refer pg 12 para 48 of the Coroner's report)  

Hmm...where's a copy of the 0342 GAF report; and why is this aberration not more closely examined as would normally be required under the ToR for a full blown systemic investigation?

Quote:Systemic

Systemic investigations can involve in‑the‑field activity, and a range of ATSB and possibly external resources. They have a broad scope and involve a significant effort collecting evidence across many areas. The breadth of the investigation will often cover multiple organisations. Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes.

In addition to investigating failed and missing risk controls, systemic investigations may also investigate the organisational processes, systems, cultures and other factors that relate to those risk controls, including from the operator, regulator, certifying and standards authorities. Systemic investigations result in substantial reports, often with several safety issues identified.

Systemic investigations were previously known as 'complex' investigations. The change in terminology more accurately reflects the broad scope and systems-level complexities involved in these investigations.

Which brings me to some extracts from both the AO-2018-078 prelim and update reports: (click on the applicable links: https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-078/ )

Prelim report:

Quote:Ongoing investigation

The investigation is continuing and will include examination of the following:

• recovered components and available electronic data
  
• aircraft maintenance documentation
  
• weather conditions
  
• pilot qualifications and experience
  
• operator procedures
  
• research and previous occurrences.
  

 
Update:

Quote:Updated: 6 December 2019 

The investigation into the collision with terrain involving Pilatus Britten-Norman BN2A, VH-OBL, 101 km west-south-west of Hobart, Tasmania, on 8 December 2018 is continuing. A preliminary report outlining the then known facts of the investigation was published on 4 February 2019.

Since the publication of the preliminary report, the investigation team has gathered information from, or related to the accident, to build a detailed picture of the event including:

• recovered aircraft components and available electronic data
  
• aircraft maintenance documentation
  
• weather conditions
  
• pilot qualifications and experience
  
• operator procedures
  
• research and similar occurrences.
  

The investigation team is currently examining and reviewing the evidence to determine its relevance, validity, credibility and relationship to the accident and other pieces of evidence. Based on this analysis, the team is developing and testing a series of hypotheses to determine the safety factors that could have contributed to the accident or increased the risk of the accident occurring and will form the basis of the ATSB final report.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant stakeholders so appropriate and timely safety action can be taken.

Hmm...so one year in and it was still considered an investigation defined by the dot points above: 

Quote:Defined

Defined investigations seek to identify systematic safety issues that reveal underlying cause of the accident. They involve several ATSB resources and may involve in-the-field activity or be an office-based investigation. Evidence collected can include recorded flight and event information, multiple interviews, analysis of similar occurrences, and a review of procedures and other risk controls related to the occurrence.

Defined investigations result in a report of up to 20 pages and look at transport safety accidents and incidents of a more complex nature than short investigations. They include an expanded analysis to support the broader set of findings within the report and may include safety factors not relating directly to the occurrence. Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. The report also identifies safety issues, along with proactive safety action taken by industry and ATSB safety recommendations.

Q/ So what changed and when did the ATSB make the decision to escalate (and commit the significant extra resources) to define this investigation as 'systemic'? Q/ Why didn't the Coroner/Police investigations note any significant organisational issues/deficiencies within the operator and/or CASA regional office?

On a final note, which I believe is definitely related, has anyone else checked out the bizarre, totally disconnected safety issue addressed to CASA, that was subsequently escalated to a very rare Safety Recommendation??

Quote:Regulatory management of repeat safety findings

The Civil Aviation Safety Authority’s acquittal process for repeat safety findings was not effective in ensuring that all previous findings of a similar nature were also appropriately assessed prior to the current and all associated safety findings being acquitted.

---

Safety recommendation
Action number: AO-2018-078-SR-01
Action organisation: Civil Aviation Safety Authority
Date: 20 December 2021
Action status: Released

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority amend its acquittal process for repeat safety findings to ensure it is effective in ensuring that all previous findings of a similar nature are also appropriately assessed prior to the current and all associated safety findings being acquitted.

Hmm...anyone else understand that gobbledygook -   

Quote:Response by Civil Aviation Safety Authority

The Civil Aviation Safety Authority did not provide a response concerning its intention to address this safety issue.

If I was the CASA Regional Manager, supposedly tasked with responding to that bollocks SR, I wouldn't  be providing a response either?? - FDS!        

MTF...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 10-21-2022

Sydney Sea Plane crash (Anna Bay) Coronial inquest begins 

Via the SMH:

Quote:Role of carbon monoxide in seaplane crash was not considered until years later, inquest told

Georgina Mitchell
Updated October 17, 2022 — 6.59pmfirst published at 2.07pm

The possibility that carbon monoxide caused a seaplane pilot to become disoriented and crash was not investigated until two years after the tragedy, an inquest has heard, with the coroner urged to recommend routine testing for the toxic gas in the future.

Pilot Gareth Morgan and five British tourists were killed on December 31, 2017, when their scenic flight from Cottage Point in Sydney’s north to Rose Bay in Sydney Harbour crashed into Jerusalem Bay shortly after taking off.


Died in the crash: Pilot Gareth Morgan, Emma Bowden, her daughter Heather Bowden-Page, Richard Cousins, and his sons Edward and William.

Several witnesses who observed the crash tried to dive down to rescue the occupants before the plane sank, but the water was too murky and filled with jet fuel.

In an opening statement on Monday, counsel assisting Sophie Callan, SC, said Richard Cousins, his sons Edward and William, his fiancee Emma Bowden, and her daughter Heather had been on holiday in Australia ahead of Richard and Emma’s planned wedding in 2018.

On December 31, they travelled by seaplane to have lunch at the Cottage Point Inn and were flying home when the plane unexpectedly circled in a different direction and crashed at 3.14pm.

Callan said the pilot sustained significant injuries and was unlikely to have regained consciousness after the crash. The others on board died from a combination of their injuries and being submerged in the water.


An undated photo of the plane that later crashed into Jerusalem Bay, killing its occupants.CREDIT:AUSTRALIAN TRANSPORT SAFETY BUREAU

An investigation by the Australian Transport Safety Bureau (ATSB) concluded that elevated levels of carbon monoxide were present in the cabin of the plane, affecting the pilot’s ability to fly and most likely causing the crash.

Mechanical examinations suggested that the colourless, odourless gas leaked into the engine bay due to cracks in the exhaust system, then leaked into the cabin because three bolts were missing from the plane’s front instrument panel.

Callan said the gas could have passed through the holes from the missing bolts. The inquest is also expected to hear evidence that one part of the instrument panel was upside-down, potentially allowing further gas to escape.

The inquest heard carbon monoxide was only examined as a potential contributor to the crash in late 2019, two years later, when an aviation medical specialist examined a draft report and suggested investigators look at carbon monoxide poisoning.


The wreckage of the plane is recovered by police and transport safety authorities on January 4, 2018.CREDIT:WOLTER PEETERS

Callan said it appears that police and the ATSB wrongly assumed a chemical byproduct of carbon monoxide was routinely checked for in toxicology screening. Blood samples retained from the autopsies were examined, revealing all passengers had the chemical, carboxyhaemoglobin, in their systems.

Morgan had the chemical in his blood at a concentration of 11 per cent. Experts are expected to give evidence that a level of 10 per cent is sufficiently high to cause adverse physical and cognitive effects.

Callan said the delay in focusing on carbon monoxide meant 2½ years had passed between the crash and authorities being able to issue bulletins to remind plane operators of the dangers of the gas.

Detective Sergeant Michael O’Keefe, who led the police investigation, said he received the additional test results in March 2020. He said if carbon monoxide was routinely screened for in autopsies, it would have quickly become the focus of the investigation.


Police respond to the scene of the crash on December 31, 2017.CREDIT:JESSICA HROMAS

“We would have saved a lot of time, and it would have saved the relatives and family probably a lot of pain over the years,” he said.

He said the coroner should consider recommending routine testing be carried out for deaths involving vehicles that produce carbon monoxide, if a cause of death was not immediately obvious.

“We might be surprised with the number of positive results we might get,” O’Keefe said.

The inquest heard Morgan, 44, was a highly experienced pilot and a gifted athlete who had a devout Christian faith and had been on missions to Mexico and Mozambique.

Richard Cousins, 58, was remembered as the chief executive of catering company Compass and a lover of cricket, who had just attended the Boxing Day Test with William, 25, and Edward, 23.

William, a press officer and parliamentary speechwriter, had recently been commended for talking down a suicidal person on a bridge at the Thames. Edward, who previously taught at a refugee camp, had just passed his entrance exam to be a police officer.

Emma, 48, who worked at OK! Magazine, was a lover of travel, cinema, theatre and cycling. Heather, 11, had started a school newspaper and starred in a play. She had big dreams to study at Cambridge.

The inquest continues.

MTF...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 10-22-2022

B200C rollback incident YMEN?? -   

Via Popinjay central:

Quote:King Air uncommanded power reduction highlights importance of friction lock tightening



Key points

• A King Air departing Essendon for Albury yawed to the left during take-off roll;
  
• ATSB found that the left engine power lever had migrated rearwards as the friction lock had not been sufficiently adjusted during the pre-flight checks;
  
• King Air power lever friction locks require careful adjustment to prevent power lever migration, particularly during take-off.
  

The insufficient tightening of a friction lock during pre-flight checks resulted in a Beechcraft King Air’s left power lever migrating to idle during the take-off roll, an ATSB investigation report details.

The King Air B200C aircraft, operated by Pel-Air, was departing Essendon for Albury on the night of 19 August 2021 to conduct a medical retrieval flight with a pilot, paramedic and doctor on-board. During the take-off, the aircraft experienced a reduction in power on the left engine and an uncommanded yaw to the left.

The pilot, who had about 16,000 hours of aeronautical experience, of which 42 hours were on the King Air B200C, initially managed the situation as an engine power loss and focused on maintaining directional control. However, when troubleshooting, they identified that the left engine power lever had migrated rearwards to the idle position. In response, the pilot moved the power lever back to take‑off power and adjusted the friction lock to prevent further movement.

The flight continued to Albury without further incident.

“The King Air’s power lever friction locks require careful adjustment to prevent the power levers moving inadvertently, particularly during take-off,” said ATSB Director Transport Safety Dr Stuart Godley.
“This is a characteristic generally known among King Air operators and pilots.”

When interviewed by the ATSB, the incident pilot reported that they were new to the B200C and unaware that power lever migration could occur during take‑off.

Another pilot from the operator noted that, until a pilot experienced a power lever migration, it could be difficult to know how much to tighten the friction locks.

“The power lever friction locks fitted to the King Air require careful adjustment to prevent power lever migration during take-off,” said Dr Godley.

“Operators should ensure pre-flight checks provide opportunities to confirm friction lock settings before the take-off run, and ensure pilots have adequate knowledge of friction lock sensitivity to help prevent and recover from inadvertent power lever migration.”

Dr Godley said the ATSB has released a safety advisory notice to all operators and pilots of King Air aircraft advising of power lever migration and the need to be aware of the careful adjustment required for the power lever friction lock.

“This incident highlights the importance of having a detailed understanding of the characteristics that may be specific to an aircraft type,” he said.

“In the case of the King Air, the design of the power lever system means that the friction locks requires careful adjustment to prevent power lever migration.”

Read the report AO-2021-034: Uncommanded power reduction involving Beechcraft King Air B200C, VH-VAH Essendon Fields Airport, Victoria, on 19 August 2021

Hmm..why does this sound so familiar??..

Quote:UK Air Accidents Investigation Branch investigation (7/2003)

On 23 December 2000, a Beechcraft B200 aircraft departed Blackbushe, United Kingdom to Palma, Spain on a private flight. Shortly after take‑off, the aircraft was observed to bank left before colliding into a factory complex 13 seconds later, resulting in a fire. All on board were fatally injured.

An examination of the aircraft did not identify any technical issues that would have contributed to the accident. However, analysis of the cockpit voice recorder showed a reduction in one of the propeller’s rpm as the aircraft rotated, which would have led to thrust asymmetry. The investigation concluded that, it was probable a migration of a power lever due to insufficient friction being set had occurred. It was also noted that the friction control had been slackened during recent maintenance and it was possible that it was not adjusted adequately by the pilot when doing their checks prior to take-off. As a result of the investigation, a safety recommendation was made to Raytheon Aircraft Company:

Quote:The Raytheon Aircraft Company should ensure that reference to the correct adjustment of power lever friction is suitably emphasised in the Beech 200 Aircraft Operating Manual (AOM) and the consequences of insufficient adjustment are not only highlighted in the AOM but also included in the recommended Beech 200 type training syllabus.

The ATSB was unable to find any follow-up action on this recommendation recorded in the investigation site.

MTF...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 10-29-2022

Questions for the Coroner?? - Part I

Via Search 4 IP: 

(10-27-2022, 04:23 PM)Kharon Wrote:  Probity - As you like it – Or; perhaps not....

This ramble, based on collective opinion was prompted by the 'passing strange' published investigation report, into a seriously 'non-event' sponsored and fronted by Godley, big cheese in the ATSB Goon squad, under the command of the Wee Bearded Popinjay. A pointless report, hardly worthy of media cover, not if taken at face value. So, a pilot's power lever wandered from the desired position – the pilot returned said power lever to correct position, reset the throttle friction and continued on; probably thinking 'must remember that'. It has happened to hundreds of B200 pilots – at least once. So why is ATSB, Godley and crew wasting resources promoting a 'something nothing' event we wonder. In defence of the Essendon DFO build perhaps, timing is all?

There's not too much to 'like' about the investigation of the Essendon DFO event. IMO it has been a shambles from the get go. But, just for the moment lets put the dubious parentage and approval for the DFO monstrosity out of the frame and focus on the crash event. Bear with the ramble while we examine some elements which could, perhaps, be of some interest to the Coroner, those left behind wondering, et al.

In general, most pilots pretty much follow a well beaten track pre departure; check the weather forecast, rearrange flight plan as required, check the weight and balance, order fuel if needs be, erc. Then amble out to do the pre flight checks and prepare the aircraft (more or less). The B200 manual provides a 'Before Engine Start' check list (41 items in my book). Many of which may be checked before loading passengers and baggage; this for practical purposes – a fault in any system is best detected prior to loading. This check list (my book) does not mention 'trim tabs' at this stage, but it does focus on 'cockpit' system. Most pilots would, at this stage at least note the position of both the roll and rudder trim wheels; almost automatic to reset to Zero at this stage.– Bear in mind that the 'after landing checks' (and SOP) call for the trim tabs to be reset to 'zero', after landing – a habit forming ritual. Even then, most pilots would check, as a matter of routine, the 'tech log' first; engineering often tinker, and may not have 're-set' before exiting the cockpit. However, had maintenance been carried out, it would be noted and the tech-log is usually checked first by the crew.

Either way, to any pilot experienced on type any serious out of trim zero setting would, on balance, be spotted while doing the pre-flight. It is probably worth mentioning here that during the pre flight 'walk around' (external checks); checking the physical position of all trim tabs, against witness marks is a written requirement, this to check the veracity of external position indication against the cockpit indicators.. Even so – in my B200 book, the Before Take Off check list also focuses the pilots attention on 'flight controls' and Trim. The elevator control wheel is a large round item, next to the pilots right knee; the rudder trim is directly within the sight line, below and just slightly to the right – can't miss it. But even then, the check list goes on to itemise 'Trim Tabs'. Even to the lay mind, it must by now becoming obvious that any pilot would have a hard time 'missing' a gross miss set of an essential, potentially lethal mandatory check list item.

ATSB report categorically states that there was a gross rudder trim setting error and cite this as the fundamental cause of the event....

For a moment consider the percentage chances of that statement actually being correct. The questions which demand answer have not been examined. The big one is “Why'. With 'how' running a close second. While you consider this, please remember back to flying lesson number one; from that point onwards; for any aircraft flown, the setting of 'trim' and throttle friction has been an essential element; drummed in hard and often. It becomes a deeply ingrained habit, a good one, most essential to not only efficient, safe, comfortable operations, but an imperative during any 'emergency/ abnormal' procedure. Almost a reflex action to any disciplined pilot who has progressed beyond first solo. While on the subject, put your hand up if you have ever forgotten to reset after landing and taken off again shortly thereafter – think back to the speed you where doing on the runway, when the Penny dropped – well below rotate speed perhaps? Anyone with more than a handful of hours in the B200 would pick up a gross rudder out of trim condition at about  40 knots and have it corrected before 50 knots, half a turn is all it needs – remember the rudder of the B200 is a powerful force – it needs to be for OEI operation.

So, this all comes back to the pilot on the day. Was he distracted – did the phone ring; or was there an urgent call from nature during the pre flight interrupting the check list half way through checking the set of the trims? Has ATSB defined why multiple opportunities to note an out of trim condition were not taken; interruption/distraction as a possibility, or was it something else? Like perhaps the trim was set correctly pre flight and impact forces drove the indicator to 'full' deflection. That is a higher percentage chance than an cognisant pilot 'missing' the check. Was the pilot actually 'fit for duty' that day? We still don't know in detail. There is a wide range of 'medical' possibilities, both physical and psychological existing within the ambit of reasonable, reasoned consideration. Should these elements have been exhaustively eliminated as part of the ATSB investigation and presented to the Coroner?

Only my opinion; but one shared by many, those that believe the ATSB investigation into this event needs to be re-examined in detail. It ain't 'wrong' but it seems 'off' somehow. There are several items which raise elements of reasonable doubt to the the interested, experienced reader. The eye-brow raising begins with the mad dash to the crash site by the the then director Hood, he arrived before the smoke and dust cleared – unusual to say the least – the risk of scene contamination just for a start.  Then the adamant pronouncement that the rudder bias set full left was 'the' sole cause; wrong? – No – but way 'off' for a lay down misere. This followed by the bizarre pronouncement that the DFO building was indeed a safety item, of benefit to the travelling public even. For (according to Hood) had the aircraft hit the freeway then the carnage would have been greater – WTD !? Had the event occurred just a little later in the day and hit the building 20 feet lower the carnage would have been horrendous. Definitely 'Off' – a safe bet there.. The whole investigation seems to have been 'cack-handed' particularly when compared to the British and American examinations of 'similar' events. Then there is all the fuss about the timing of the report, the delays, the obfuscation about the DFO approvals and endless 'legal' speculation on runway width safety zone impingement. When you listen to Senator's questions in Estimates, one of the glaring sleight of hand answers confounds the Questioner; but not industry experts. The questions surrounded the mandatory 'safety zones' required each side of operational instrument runways. The 'Splay'. The glib, answers easily brought the Senators to a point where, for lack of wider knowledge, they were fobbed off with take off and landing vertical 'margins' – i.e straight ahead, but the requirements for mandated 'width' of 'safety zones' was neatly avoided. There is a case to answer right there, make no mistake about it..

Nearly there; last, but by no means least we must consider the pilot. There are three items of note which seem to have been 'eliminated' from the ATSB investigation. Both Coroner and legal Eagles would be well served by requesting and requiring some 'medical' opinion; even if just to eliminate these elements 'from our enquiry' - so to speak.

At least two independent physiological and psychiatric opinions must be provided for consideration. (If it was my call, I'd have the autopsy revisited to boot). I make this remark after conferring with over twenty experienced Check pilots, Chief pilots and highly experience flight crew. I have also canvassed to subject with two highly qualified medical men and one very astute medical lady. All considered it important (given the events on the day) that a full history across the medical disciplines would be beneficial to inquiry; beginning at least two years prior to the incident at Mt Hotham. For it was that day which should have rang a lot of large bells, very loudly.

Revisit the Mt Hotham event. In the beginning was the proposed charter operation to Mt. Hotham; quite complex involving several aircraft arriving within a given time frame at a non controlled aerodrome, within a given set of arrival times. Routine, just another day in a charter pilot's life. The events at Hotham were, to say the least, very concerning from an operational standpoint. It is reasonable to say that most Chief pilots would have grounded the pilot immediately after landing. While the list of 'errors' is troublesome; the reasons for persisting with the flight path flown that day are alarming. Disoriented and quite probably 'lost' with traffic overhead and below, in cloud, over mountainous terrain; 99.9% of professional pilots would have climbed to a lowest safe height, gone a distance away (clear air), let the holding aircraft land, take time to compose both heart and mind and returned to execute the approach as specified. Quartermain persisted in what I consider a very dangerous exercise, endangering not only his own command, but other aircraft and the passengers within. That, stand alone demands serious attention and considered expert opinion on residual mind state at the time of the DFO event. Then there is the physical condition of the pilot to consider – medication, reason for same, side effects, fitness to fly, etc.

Then consider the Essendon take off and subsequent collision with a building that should never have been placed where it is. Was the building 'complicit' or at least a contributing factor to the deaths? Perhaps there was a fighting chance for the pilot to recover the aircraft, given a little more clear air within the boundaries of the runway as they were before 'manipulation' shifted to odds.

Lets look at the aircraft track from zero to collision and consider the actions of the pilot from the 'cleared for take off' – to the full stop on the roof of the DFO. Consider the time line. Start the clock:-

“Cleared for take off etc..

Ok – here we go, hand on BOTH power levers – power increasing – all good 40 knots and “bugger me” we are off the centre line; now count ::100, two hundred; three hundred – most pilots would have by the end of that count, checked the whole flight system; engines reading correctly; trims set (Uh-Oh) lots of right leg required (50 Kts) rudder trim out (reset) 60 Kts back on centreline – no bells and whistles – V1, Vr and off we go to Golf.

So why was one of three reasonable options not actioned? 1 – Abort – power off, brakes on, exit runway return to base. 2 – Engine not performing; abort. Repeat the above. 3- Left rudder trim hard over – reset and continue perhaps. But no; just an increasing loss of control and multiple Mayday calls from airborne, right until the bang at the end of the short journey.

Did all the holes in that famous slice of cheese line up? Technically, they did. But to me, it seems the 'official' knitting became unravelled long before the final stanza was played. Humans are fragile creatures, was this pilot subject to things beyond his control or knowledge; did a flash back to Hotham freeze his reasoning faculties? Did he have a 'brain bleed' '? Was his medication (if any) in some way connected; could he have recovered if not for the DFO obstacle?. We just don't know; but one thing is absolutely damned certain. There has been a hanger full more money, time and effort spent in an attempt to deny that the DFO was, in any way, shape or form, parked in the wrong spot than poor old Quartermain has had lavished on defining exactly what went wrong that day and why. A lesson denied? A report as left hand biased as the alleged rudder trim was? Some folks died that day; it could have been worse, a whole world worse and yet the DFO still stands, all legal and correct they say; I wonder....

Ayup...Add it all together and ask was there a clearly defined pathway to the inevitable future incident or accident. I just don't know; but had I been his Chief pilot it would be a long, long while after Hotham before I turned him loose, unaccompanied. Even then, before that he'd have to get through the Devil's own check ride after medical evaluation (mind and body). It is a wonder CASA let it all slide away as easily as it did; just another small wonder of the many.

Now the Brits lost a B200 at Blackebush; the flight path, time frame and result equal to our homegrown version. The Brits nailed it; tick, correct answer. Australia's ATSB grabbed the first straw on offer indicating 'pilot error' and neatly, but elegantly shot themselves in the nether regions (their arse for the unlettered).

My venerable, ancient Pelican (Grumble to us) came up with a ripper suggestion;  verbatim I do quote it.  “What if Old mate shoved on the coals and then spotted the misaligned rudder trim; took his paw off the taps to adjust that and the throttle drifted back – brain fade – Hotham flash back – brain crash - May day – no valid escape route or remedial action due to lack of cognitive action”. Not too bad a notion is it. Then there's P7's question - “was the rudder trim hard over setting created by the impact forces, it is only a mechanical link system, a good wallop in the right place could have forced mechanical linkages in that direction”. We just don't know; but the Brits report made 'good sense' – the American reports are credible – the ATSB version; not so much. Perhaps the ever increasing lack of operational credibility (see Pel Air, MH 370 and Angel Flight) has influenced that notion; perhaps; but whatever is influencing ATSB reporting on fatal accident needs to be gone; tout de suite – and the tooter the sweeter, in our most humble opinion.

End of opinion piece – I shall now return my thumbnail to the tar pot. But I say ATSB has become a thoroughly dysfunctional outfit. No longer fit for any purpose bar providing top cover and credible deniability for those very, very few who need it. Like those who know the DFO needs to be demolished but dare not acknowledge it – lest the rice bowls are taken away.

That's it.

Toot – toot.

Okay then, to the dots-n-dashes...  

To begin it is hard not to draw the conclusion, that the former Hooded Canary led ATSB, had drawn a conclusion/hypothesis that strongly supported the degraded performance of the pilot and his possible normalised deviance of not adhering to B200 preflight and pre-takeoff checklist procedure: ref - https://theconversation.com/lessons-learned-from-the-essendon-air-crash-the-importance-of-pilot-checklists-103834 & Mr Hood said the pilot had five opportunities to pick up the error that led to the crash. 

 

However let us rewind to the day after the tragic DFO accident, with reference to this Age article:
https://www.theage.com.au/national/victoria/essendon-air-crash-investigators-scour-plane-wreckage-find-interesting-facets-20170222-guif2a.html

Quote:"With any accident, particularly aviation accidents, we find that initially there are several factors that leap out at you," Mr Hood told reporters on Wednesday.

"The investigators are trained not to put any bias on what is the obvious.

"So whilst in the initial walk-through [on Tuesday], the initial examination of records, we have discovered some interesting facets, we really need to gather all the evidence and conduct the analysis before we can say what caused the accident..

..Fairfax Media revealed Mr Quartermain was the subject of a long-delayed ATSB investigation over a safety incident while flying a similar model of plane in 2015.

Mr Hood said he was unaware of the pilot's previous history, and refused to answer questions about why the investigation has not yet been completed, nor whether Mr Quartermain, 63, was safe to fly."

Now ffwd 17 months to the release of the final report (which for such a high profile, complex systemic investigation must be close to an ATSB record for completion?), where the Essendon Fields airport operator put out this statement (my bold):

Quote:ESSENDON FIELDS STATEMENT – FINAL ATSB REPORT

SEPTEMBER 24, 2018|IN AIRPORT|BY ESSENDON FIELDS

Essendon Fields Airport today welcomed the release of the final ATSB report into the tragic events on 21 February 2017 which resulted in the deaths of five people.

The release of this final ATSB report is important to help ensure some closure for the widows of the victims both in the United States and Australia and the thoughts and best wishes of everyone at Essendon Fields are always with those families.

The ATSB investigation has confirmed in great detail the circumstances relevant to the events of that day. The report’s finding outlines clear contributing factors to this accident and additional factors that increased the risk of what happened in February 2017. The report provides several strong safety messages relevant for the entire aviation industry.

The significant public interest into the circumstances of this tragedy will ensure the learnings from this report will strengthen the already impressive safety record for the entire aviation industry in Australia. Safety remains the first priority at Essendon Fields at all times.

The final ATSB report makes it clear the operation or conditions at Essendon Fields Airport played no role in this terrible crash.

The report confirms that the presence of the DFO building struck by the aircraft did not increase the severity or the consequences of this accident. This building is not subject to further investigation.

The ATSB is conducting a separate investigation into the approval process of two other buildings at Essendon Fields DFO. We note those buildings were approved by CASA prior to construction. Those two buildings did not contribute to this accident.

Essendon Fields Airport looks forward to the release of the report into the building approval process and will continue to work co-operatively with the ATSB on this investigation. Until then it is not appropriate to comment further on this matter.

Chris Cowan, CEO

   
  
Hmm...so did they get the conclusion that they (desperately) wanted ie pilot error?? - 

Now ffwd again (with the DFO approval process investigation then in it's 3rd year) to this Oz article:

Quote:Pilot’s ‘tendency to confuse instruments’ to be raised in inquest

FRANCES VINALL

6:57PM MAY 28, 2021

A pilot who crashed a light aircraft into a shopping complex may have had a tendency to get instruments confused and “an overall lack of situational awareness when operating aircraft”, a court has heard.

A Coroners Court of Victoria inquest will investigate the circumstances that led to a plane crashing into DFO Essendon in 2017, bursting into flames and killing all five people on board.

A pre-inquest hearing on Friday heard pilot Max Quartermain may have either failed to notice a key problem with the plane’s rudder trim position or accidentally set the position wrong himself.

Counsel assisting the court Liam Magowan said of Mr Quartermain: “There is some suggestion in the evidence that Mr Quartermain did not always undertake the mandatory flight checks and that appropriate systems may not have been in place”.

“There is some suggestion in the evidence that Mr Quartermain had demonstrated a tendency to confuse instruments,” he added.

“By this I mean, an intention to operate one instrument, but mistakenly operating another.”

The B200 Super King aircraft was supposed to fly that morning from Essendon Airport to King Island, off the coast of Tasmania.

On board were American tourists Greg De Haven, Glenn Garland, Russell Munsch and John Washburn.

On February 21, 2017, the plane prepared for takeoff just before 9am with instructions to turn to the right.

Instead, “witnesses familiar with the aircraft type noticed a noticeable yaw to the left”, Mr Magowan said.

It reached 160 feet while tracking an arc to the left and was only in the air for 10 seconds before it began to descend.

The pilot frantically transmitted seven “mayday” signals over the Essendon Tower radio frequency.

Two seconds later, it collided with the roof of the shopping centre building and crashed into a loading area, bursting into flames.

The Australian Transport Safety Bureau found: “The primary physical cause of the accident was that the aircraft’s rudder trim was likely in full nose left position at the commencement of the takeoff”.

“How the rudder came to be in that position is likely to be, broadly, the issue of this inquest,” Mr Magowan said.

“There may be issues as to Mr Quartermain’s practice in relation to compliance with civil aviation regulations.”

The inquest may also examine if it was a good idea to have a retail outlet centre so close to Essendon Airport.

“The retail outlet centre is located, in effect, at the end of (a) runway,” he said.

The inquest is slated to run in September.

Finally to add some dots on the "K" post (quoted above), here is the photo depiction of the rudder trim: 


It can be seen that from full left to full right it is approximately a 160 degree turn and to neutral approximately a 80 degree turn. From experience, for an averagely skilled pilot, it is a relative basic action to reset to neutral within 3-5 seconds. and with a pilot familiar with B200 it is a natural action when conducting OEI asymmetrics and indeed through the phases of normal flight ie T/O, climb, cruise, descent and landing.

Next the loose power lever friction nut, this is what was said in AO-2017-024 FR:

Quote:Power lever roll back (creep)

Throughout the investigation, the ATSB spoke with numerous B200 pilots who highlighted the importance of ensuring power lever frictions were adequately tightened prior to take-off. In their experience, if inadequate power lever friction was set, the power levers could ‘creep’ back from the full-power position when the pilot removed their hand from the levers after take-off.

If power lever movement is not noticed, the aircraft may not climb and accelerate normally, and rudder force may be required to keep the aircraft straight. In addition, the auto-feather system will be disarmed if either power lever moves back past the ‘90% engine’ speed position (refer to section titled Autofeather system below).

Now refer back to the very similar UK AAIB B200 fatal accident - HERE

TBC...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 10-30-2022

Just thinking 'out loud' here.

There is a claim made the by ATSB into the Essendon DFO event which states the aircraft was 240 Kilos overweight (there or thereabouts). There is an additional claim that the 'take off roll' was longer than it should have been.

ATSB have been very coy in defining the 'base load' data used to reach these assumptions. This effectively prevents external confirmation of their data set and nullifies any counter argument to their claim of investigative probity. Problem is, some of it is simply hand woven distraction, just shy of outright obfuscation. For example:-

The 'ground roll' calculations; all this horse pooh relating to Raytheon and tailwind factor and etc. is plain, flat out guess work. Let me explain; there are three options available to a King Air pilot; One:: steadily set take off power (or close to) before releasing the brakes for a 'short filed' take off. Two, normal steady increase to maximum grunt within the confines of runway length, surface conditions etc. Three: Bang 'em up to the stops and await the bollocking from both engineering and the CP on return.  Turbines need a little time to spool up, it ain't instant, best to lead gently to full song, and listen and watch as they get there. In the routine situation; most pilots will not be messing about getting the power on; but between the two extremes, on a normal operation, the time taken varies between pilots; some quicker, some slower. This will effect the length of ground roll, BUT it has sweet sod all to do with why 'this' crash into a building occurred; absolutely nothing.

This is the part where, to professional pilots, experienced on type 'suspicion' begins to creep in. If a thing like the 'factory test pilot' length of the take off roll (+/- 50 metres) can be woven into a yarn, then the rest automatically becomes suspect. Then the external, independent, expert investigations begin in earnest.

For another example (one of several) – ATSB claim a 240 Kg overload: really? Well boys, grab a pencil and get out the books. I did. Flight planning 101. How far is there to go? Can I carry return fuel given the weather and the load and ATC requirements. Yes; then upload the fuel required (plus a bit for Mum and the Kids) but do not exceed a take off weight which will, given the conditions and the chance of needing to operate with one engine inoperative while avoiding obstacles ahead, 'difficult' in a FAR 23 aircraft. Max Ramp weight (Be 200) 5710 Kg:: Max Take off weight – 5670 Kg; that boys and girls allows a 50 Kg margin for taxi (-10 for each start up + run up and checks – say another 10. 20 kg) and holding point aggravation uncertain.. Uhm, how long was the accident aircraft on taxi and holding point before line up? How much fuel was burnt two starts, checks, two taxi legs; all fuel out of tanks.  Not calculated or even mentioned is it.

So what of the flight fuel requirements? ATSB have not provided data which would allow an evaluation of the 'actual' requirements; ATC and weather considerations etc. But, even so; when I add 100 Kg to the 'executive' configuration weight I have on file (it was a heavy one); and plan the flight manually, on book figures; and allow for the  minimum uplift (if required) at King Island prices; it is 'difficult' to parlay that into an assumed 240 Kg overload. Mind you, I did plan it at F200; 1700 PRPM, best economical (no rush for 160 nautical mile flight); working the plan to a 12 minute climb (150 lb of fuel and 38 ground miles) - (no wind data) a 14 minute descent (62 ground miles and 140  lb of fuel) which gave me 26 ground miles to cover at (say) 260 knots. Allow for an approach (say 12 minutes at holding rate, allow 5 minutes for a circuit – and – on book figures, nil wind – and allowing for a twenty minute (delay' ATC diversion) on return to Melbourne. I am still at worst at MTOW at the beginning of the flight. That is after allowing 100 kg per passenger; 4 x 20 kg each (bag of concrete) for golf clubs and 10 Kg a piece for accessories (lap tops, cameras, etc) I cannot find much more than the difference between Max ramp weight and MTOW; which, even without subtracting the first start up, engine checks, taxi to pick up point, second start and taxi and line up, the fuel load at start up just does not add up to a 240 kg over weight take off, no where near it. Not when the aircraft only loaded 1485 kg of fuel.

Non of this means anything to aviators – it's just the usual ATSB spin, working to fool some of the people, most of the time. But glaring misdirection, exposed by switched on legal counsel will tear it to shreds; for it is wide open. This further discredits the ATSB and interferes with a 'righteous' outcome. We all want to know the how and the why of this accident; just can't quite see it clearly, through the unnecessary smoke and mirrors.

Not anywhere near good enough by world standards and even for the ATSB after multiple 'butchered' reports, it is a new low.

Toot toot.

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 12-19-2022

ALL SHAME no FAME for POPINJAY - 

Via the Search 4 IP:

(12-15-2022, 07:22 PM)Peetwo Wrote:  Popinjay recommends TAWS for GA Aircraft; & still waiting for DFO final report??

From the Chief Commissioner who refuses to investigate a double fatal midair collision accident near Gympie - : 

Quote:ATSB urges fitment of terrain avoidance and warning systems to smaller passenger aircraft



Key points

• Aircraft was being flown 1,000 ft below the recommended descent profile, and had probably entered areas of significantly reduced visibility, including heavy rain;
  
• The pilot was probably experiencing a very high workload, and it is evident they did not effectively monitor the aircraft’s altitude and descent rate for an extended period;
  
• A TAWS (terrain avoidance and warning system) would have provided the pilot with both visual and aural alerts of the approaching terrain for an extended period.
  

A Cessna 404 with a pilot and four passengers on board was being flown 1,000 ft below the recommended descent profile before it collided with sand dunes about 6.4 km (3.5 NM) short of the runway at Lockhart River, an ATSB investigation report details.  

Read the report: AO-2020-017 Controlled flight into terrain involving Cessna 404, VH-OZO, Lockhart River, Queensland, on 11 March 2020

Publication Date
15/12/2022

Via this week's #SBG 18/12/22:

Quote:To the Pale – and then; beyond.


Oh, I love a ducked up country,
a land of counter claims
a land of government agencies,
that listen carefully to complains,
a purpose of avoiding all the blame.

A land of broken aeroplanes,
Of pilot's widows grieving,
awaiting someone to explain
Why their loved ones went away
and won't come home this Christmas day...Anon...

Hmm...POPINJAY TO THE RESCUE! - 

Next I go in search of an update on the Essendon DFO cover-up:

Quote:Aerodrome design changes and the Bulla Road Precinct development at Essendon Fields Airport, Melbourne, Victoria

Update published 1 August 2022[/i]

The ATSB undertook a significant review of the available material and sourced additional evidence from organisations in Australia and overseas following the circulation of a draft of the report to Directly Involved Parties in 2019.

Additional work was considered necessary when changes were made to the design of surfaces at Essendon Fields Airport that manage the location and height of buildings in proximity to runway 08/26. These changes were made by the aerodrome operator around the time the draft report was released for consultation. The changes were advised in update 1

The investigation has involved consideration of historically complex subject matter with the application of both Australian and international aerodrome design requirements dating back to the 1970s. The ATSB has applied considerable effort to understanding the application and function of those aerodrome design requirements from the 1970s to the present in the context of changes at Essendon Fields Airport. It has taken the investigation time to overcome the challenges of limited information available from historical periods to provide context to the investigation.

The title for this investigation has been updated to ‘Aerodrome design changes and the Bulla Road Precinct development at Essendon Fields Airport’ to recognise the scope of matters the investigation addresses.

A draft of this report was released to Directly Involved Parties for review on 15 August 2022. Directly Involved Parties have 60 days to provide comment to the ATSB. A final report is expected to be released publicly in the last quarter of 2022

Hmm...so 2 weeks out from the end of the year, where the duck is the FR Mr Popinjay??   

Via Popinjay Cover-up HQ...

Quote:Update 3???

The ATSB released a new draft of this report to Directly Involved Parties (DIPs) for comment in mid-August 2022.  As discussed in update 2, the investigation involves consideration of historically complex subject matter, with a significant focus on the interpretation of both international and domestic aerodrome standards, addressing their intended objectives.

As the ATSB is progressing this investigation, the international design standards that limit obstacles around airports are under review. This work is providing context for this investigation with the evolution of knowledge on the expectations for the design of obstacle limitation surfaces.

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

An update on timing for completion of the investigation will be provided at the start of 2023 after the ATSB has been able to complete necessary engagements with Australian and international DIPs. P2 - Good bet that there are Texan lawyers (representing the widows and their families) that are all over this??

---

Anticipated completion - Q2 2023

So Popinjay continues the cover-up - UDB! 

MTF...P2 

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-02-2023

GA Oz Darwin awards nominee for 2021; or ???

I note the following (various versions) came across the Oz domestic MSM yesterday -  : 

Quote:Unlicensed pilot charged over fatal Qld plane crash


A man, 83, was killed when the home-built, two-seater Jodel D11 aircraft crashed north of Mackay. (PR HANDOUT IMAGE PHOTO)

An unlicensed pilot will face court after being charged over the death of a passenger in a light plane he was flying when it crashed in north Queensland.

The 66-year-old man was arrested at a home in Haliday Bay, near Mackay, on Tuesday following a probe by police and the Civil Aviation Safety Authority into the fatal crash at Ball Bay Beach on December 24, 2021.

An 83-year-old man was killed when the home-built, two-seater Jodel D11 aircraft hit the sand, with the pilot also hospitalised for his injuries.

The younger man has been charged with manslaughter, flying aircraft without a licence, and carrying out maintenance and flying without satisfying safety requirements.

He's due to face Mackay Magistrates Court on Wednesday morning.

The Australian Transport Safety Bureau ended its own probe into the accident in early November after finding that due to the circumstances, there was "limited opportunity" to "uncover safety learnings" for the aviation industry.

ATSB chief commissioner Angus Mitchell noted the passenger's seatbelt, which was manufactured in 1973 and needed to be removed from service in 1990, had "completely failed".

"When owners operate outside of the rules, they remove the built-in safety defences and undetected problems are more likely to emerge," he said in a statement at the time.

Here is the media statement that was not only 'attributed' to but owned by Popinjay, back in February 2022:

Quote:ATSB discontinues investigation into fatal Ball Bay light aircraft accident

The Australian Transport Safety Bureau has discontinued its investigation into a light aircraft accident in which a passenger was fatally injured during a forced landing on a beach at Ball Bay, Queensland on 24 December 2021.

“The Australian Transport Safety Bureau conducts independent ‘no-blame’ investigations into accidents and incidents for the purpose of identifying safety issues and actions and to help prevent the occurrence of similar future accidents, and we do not investigate for the purpose of taking administrative, regulatory or criminal action,” said ATSB Chief Commissioner Angus Mitchell.

“In this tragic accident ATSB investigators established quite quickly that the aircraft, an amateur-built two-seat Jodel D11, was being operated outside of aviation regulations. 

“The pilot was not licenced to fly aeroplanes and the aircraft and engine had not been maintained in accordance with the appropriate regulations for about 10 years.

“On that basis, the ATSB has determined that there was limited opportunity that continuing to direct resources at this investigation would uncover safety learnings for the broader aviation industry.”

Mr Mitchell said investigators also determined during their examination of the aircraft wreckage that the passenger’s seat belt had completely failed at 2 locations.

“Both the pilot and passenger’s seat belts were manufactured in May 1973 and were required to be removed from service prior to 1 January 1990 in accordance with a Civil Aviation Safety Authority airworthiness directive.

“When owners operate outside of the rules, they remove the built-in safety defences and undetected problems are more likely to emerge,” he concluded.

Further details on the accident flight, information determined from the ATSB’s examination of the aircraft wreckage, and the reasons for the ATSB’s discontinuation can be found on our website here.

Publication Date
11/02/2022

And referring to the "Final Report: Dissemination"; I am (for once -  ) in furious agreement with Popinjay the decision to discontinue this investigation, especially when you consider the concise factual findings of the IIC and the investigative team up and until that point in time:

Quote:Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. The statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance.

Overview of the investigation

The occurrence

On 24 December 2021, the ATSB commenced a transport safety investigation into a fatal accident involving an amateur-built Jodel D11 aircraft, registered VH-WBL, at Ball Bay about 34 km north‑north-west of Mackay Airport, Queensland, on the same day.

At about 0740 Eastern Standard Time,[1] the pilot reported starting the aircraft at the Ball Bay airstrip and conducting engine run-ups before the passenger boarded for a private pleasure flight. After the passenger boarded, the pilot taxied the aircraft to the northern end of the runway and conducted a second engine run-up and magneto check, with no anomalies detected. The aircraft was then lined up for a take-off towards the south-east. The ground run and take‑off were uneventful until the aircraft reached a height of about 60 ft, when the engine started to intermittently cut-out. The pilot ‘pumped’ the throttle lever. However, the engine failed and power could not be restored. As there was insufficient runway remaining to land ahead, the pilot turned the aircraft left towards the beach for a forced landing.

Impact marks in the sand indicated that, during the landing, the left main wheel struck the ground first followed by the aircraft nose. One propeller blade (wooden) broke off, and the aircraft rotated and rolled onto its right side before coming to rest partially inverted about 22 m from the initial impact mark. The passenger was fatally injured and the aircraft was destroyed. The pilot was taken to Mackay Hospital and self-discharged on the same day.

The wreckage was removed from the accident site by the Queensland Police Service Mackay Forensic Crash Unit and transported to a secure facility for examination.

Pilot and aircraft history

The ATSB visited Mackay from 12 to 16 January 2022 and the investigation found that:

• The pilot did not hold a Civil Aviation Safety Authority aeroplane pilot licence, aircraft maintenance engineer licence or authorisation to perform or certify for maintenance on the accident aircraft.
  
• The aircraft was issued with a standard certificate of airworthiness in 1978.
  
• The pilot purchased the aircraft from the owner-builder in 2011.
  
• The aircraft logbook statement specified that it was to be maintained in accordance with the Civil Aviation Authority[2] Schedule 5. All components were lifed ‘on condition’, except those within the scope of relevant airworthiness directive requirements and the engine. The time‑in‑service between maintenance release issue was at 100‑hours or 12‑month intervals, whichever was earlier. The operational category was ‘private’.
  
• The most recent maintenance release was issued in 2015 by the pilot, who was not authorised to do so. The expiration date was recorded as ‘27/1/16’, the system of maintenance was recorded as in accordance with ‘Schedule 5’ and the operating category as ‘experimental private’. It contained the pilot’s daily inspection certifications for 2015 and further entries in 2021, after the maintenance release had expired (none recorded for the period 2016–2020).
  
• The aircraft logbook entries for periodic inspections in accordance with Schedule 5 ended with the last entry in March 2011. There was no entry for the maintenance release issued in 2015.
  
• The engine logbook entries ended in January 2014, with the last entry certified by the pilot.
  
• The last entry in the pilot’s logbook for VH-WBL was in 2015.
  

Wreckage examination

The ATSB conducted a preliminary examination of the wreckage, but did not identify anything obvious that would lead to the engine completely failing. Relevant observations are noted below:

• The tachometer indicated a time of about 6 minutes between engine start and the accident.
  
• The remaining propeller blade did not exhibit any damage, which was consistent with a loss of power.
  
• The core of the engine was intact with the crankcase free from impact damage and the cylinders securely attached. The engine rotated freely and the valve train was observed to respond to crankshaft rotation.
  
• A differential pressure (leak) check was performed on the engine cylinders with the engine at ambient temperature. One cylinder recorded a low result for a compression check of 16/80. The others recorded 55/80, 74/80 and 76/80.
  
• There was sufficient engine oil and the oil filter was relatively clean with no significant debris.
  
• An internal examination of the exhaust system showed that the muffler inner matrix had collapsed with loss of matrix material to both mufflers. However, the condition of the matrix should not have prevented the operation of the engine.
  
• The gascolator was dislodged in the accident and no fuel was found in the carburettor float bowl.
  
• The main fuel tank dip stick was bent during the accident and indicated there was sufficient fuel for flight at impact. This was the tank selected for the flight and was gravity-fed to the engine. The tank had split open, resulting in the loss of all the contents, and therefore no examination of this fuel was possible. The right-wing fuel tank contained blue aviation gasoline (100LL) and the left-wing fuel tank contained green fuel, which was likely a blend of aviation gasoline with yellow unleaded motor gasoline. Both wing tanks passed a water test.
  
• Although not used on the accident flight, the electric fuel pump for the wing tanks contained fuel that failed a water test. The pump filter was found to be clean and unobstructed.
  
• A functional check of the engine ignition switch did not reveal any defect with the magneto switching.
  
• The flight controls were connected and free to move in the correct sense. However, the aileron control cables were significantly corroded at their outboard thimble and sleeve.
  
• The passenger’s seat belt had completely failed at 2 locations. Both the pilot and passenger’s seat belts were manufactured in May 1973 and were required to be removed from service prior to 1 January 1990 in accordance with Civil Aviation Safety Authority airworthiness directive AD/RES/24: Aeronautique Seat Belts and Harnesses. At the time the airworthiness directive was issued in 1990, the aircraft was being maintained by an approved maintenance organisation.
  

Safety message

This accident highlights the importance of following standards for the maintenance and operation of aircraft. The Civil Aviation Safety Authority airworthiness directive AD/RES/24 regarding seat belt replacement was cancelled in 2009 with the explanation that ‘As all affected aircraft would have been modified long ago, this AD is no longer required’. However, compliance with this airworthiness directive was missed on this aircraft for about 30 years, despite both seat belts displaying the affected manufacturer’s label and their inspection was a requirement under Schedule 5.

Reasons for the discontinuation

The Civil Aviation Safety Authority have put in place regulations designed to ensure aircraft are airworthy and pilots are properly trained and qualified. When owners operate outside of the rules, they remove the built-in safety defences and undetected problems are more likely to emerge. Given that the aircraft and engine had not been maintained in accordance with the regulations for about 10 years, a more detailed investigation to find the source of the engine failure would have unlikely led to the identification of broader systemic safety issues. On that basis, the ATSB determined that there was limited safety benefit in continuing to direct resources at this investigation when compared with other priorities and elected to discontinue this investigation.

 
IMO, despite Popinjay's protestations on limited resources, that is the proper way/process for discontinuing an investigation (IE examine the facts as they are known and forensically examined), then make the decision to discontinue. Kudos to the Brisbane ATSB office -   

Pity the same principled (ICAO Annex 13) approach is not adopted for those under the YSCB bubble when it comes to making decisions not to investigate mid-air collisions?? 

Quote from the NTSB 'Office of Aviation Safety':

Quote:

1. Investigate all civil domestic air carrier, commuter, and air taxi accidents; in-flight collisions; fatal and nonfatal general aviation accidents; and certain public-use aircraft accidents; uncrewed aircraft systems accidents; and commercial space mishap accidents. 
   

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

  
  
MTF...P2 

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-24-2023

Senator Fawcett on closed safety loops and slices of Swiss Cheese? 

Those of you that have followed this thread would know the origins of the statement 'Closing Safety Loops' came from none other than Senator David Fawcett in one of his first appearances at RRAT Committee Budget Estimates:


Hansard ref: https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Festimate%2Fac4cc409-1146-463a-8fcb-70fbd6afc70a%2F0008;query=Id%3A%22committees%2Festimate%2Fac4cc409-1146-463a-8fcb-70fbd6afc70a%2F0000%22

Quote:Senator FAWCETT: I notice CASA is often another player in the coronial inquests and often you will highlight something, the coroner will accept it and basically tick off in his report on the basis that a new CASR or something is going to be implemented. Do you follow those up? I have looked through a few crash investigations, and I will just pick one: the Bell 407 that crashed in October '03. CASR part 133 was supposed to be reworked around night VFR requirements for EMS situations. I notice that still is not available now, nearly 10 years after the event. Does it cause you any concern that recommendations that were accepted by the coroner, and put out as a way of preventing a future accident, still have not actually eventuated? How do you track those? How do we, as a society, make sure we prevent the accidents occurring again?

Mr Dolan : We monitor various coronial reports and findings that are relevant to our business. We do not have any role in ensuring that coronial findings or recommendations are carried out by whichever the relevant party may be. I think that would be stepping beyond our brief.

Senator FAWCETT: Who should have that role then?

Mr Dolan : I would see that as a role for the coronial services of the various states. But to add to that, because we are aware of the sorts of findings—as you say, it is not that common that there is something that is significantly different or unexpected for us, but when there is—we will have regard to that obviously in our future investigation activities and recognise there may already be a finding out there that is relevant to one of our future investigations.

Senator FAWCETT: Would it be appropriate to have—a sunset clause is not quite the right phrase—a due date that if an action is recommended and accepted by a regulatory body, in this case CASA, the coroner should actually be putting a date on that and CASA must implement by a certain date or report back, whether it is to the minister or to the court or to the coroner, why that action has not actually occurred?

Mr Dolan : I think I will limit myself to comment that that is the way we try to do it. We have a requirement that in 90 days, if we have made a recommendation, there is a response to it. We will track a recommendation until we are satisfied it is complete or until we have concluded that there is no likelihood that the action is going to be taken.

Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you propose to engage with the coroners to make sure that we, as a nation, close this loophole to make our air environment safer?

Mr Mrdak : I think Mr Dolan has indicated the relationship with coroners is on a much better footing than it has been ever before. I think the work of the ATSB has led that. I think it then becomes a matter of addressing the relationship between the safety regulators and security regulators, as necessary, with the coroners. It is probably one I would take on notice and give a bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a duty of care and an oversight to make sure that two agencies who work for you do actually complement their activities for the outcome that benefits the aviation community?

Mr Mrdak : We certainly do ensure that agencies are working together. That is certainly occurring. You have asked me the more detailed question about coroners and relationships with the agencies. I will have a bit of a think about that, if that is okay.

Senator FAWCETT: Thank you.

This was Murky's reply to DF's QON:

 

Quote:Senator FAWCETT: Mr Mrdak, as secretary of the relevant department, how would you
propose to engage with the coroners to make sure that we, as a nation, close this loophole to
make our air environment safer?

Mr Mrdak: I think Mr Dolan has indicated the relationship with coroners is on a much better
footing than it has been ever before. I think the work of the ATSB has led that. I think it then
becomes a matter of addressing the relationship between the safety regulators and security
regulators, as necessary, with the coroners. It is probably one I would take on notice and give a
bit of thought to, if you do not mind.

Senator FAWCETT: You do not accept that your department and you, as secretary, have a
duty of care and an oversight to make sure that two agencies who work for you do actually
complement their activities for the outcome that benefits the aviation community?

Mr Mrdak: We certainly do ensure that agencies are working together. That is certainly
occurring. You have asked me the more detailed question about coroners and relationships with
the agencies. I will have a bit of a think about that, if that is okay.

Answer:


In terms of coordination between agencies there are in place a number of mechanisms that
ensure effective cross agency handling of issues in relation to safety matters having regard to
the specific legislative roles of each agency. These include the establishment of formal
Memorandum of Understanding between the Australian Transport Safety Bureau (ATSB) and
the Civil Aviation Safety Authority (CASA) and between the ATSB and Airservices Australia
(Airservices).

In relation to interaction with coroners this takes place in a number of ways. The ATSB
supports the coronial process by explaining the findings from its own investigation through the
provision of briefings to the coroner and giving evidence at inquests.

The ATSB also brings any aviation safety related issues identified in the ATSB investigation or
from the coroner’s findings to the attention of the Civil Aviation Safety Authority (CASA),
Airservices Australia and industry by publicising them on the ATSB’s website. Where
appropriate, comments are specifically sought from both CASA and Airservices, and that
information is also included on the ATSB’s website.

In relation to CASA, Airservices or the Department, all organisations participate in the coronial process when requested. Where coroner’s findings are directed at any of these organisations, the coroners’ recommendations are fully considered and where agreed, actions are implemented to enhance aviation safety.

(P2 comment: It is interesting to note the number and caliber of aviation safety QON that was generated in the May 2012 Budget Estimates, ref: https://www.aph.gov.au/~/media/Estimates/Live/rrat_ctte/estimates/bud_1213/infra/aviation_airports.ashx & https://www.aph.gov.au/~/media/Estimates/Live/rrat_ctte/estimates/bud_1213/infra/casa.ashx & https://www.aph.gov.au/~/media/Estimates/Live/rrat_ctte/estimates/bud_1213/infra/airservicesaustralia.ashx & https://www.aph.gov.au/~/media/Estimates/Live/rrat_ctte/estimates/bud_1213/infra/corro/ctte_atsb.ashx & https://www.aph.gov.au/~/media/Estimates/Live/rrat_ctte/estimates/bud_1213/infra/corro/ctte_atsb_response.ashx )

 That question and answer was followed up by DF in the Supp Estimates session in October 2012, which was incidentally a week before the PelAir inquiry began:    

(From 01:50 minutes)

Hansard ref: https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Festimate%2Face48424-b386-4d7d-82b4-100e492c8018%2F0005;query=Id%3A%22committees%2Festimate%2Face48424-b386-4d7d-82b4-100e492c8018%2F0000%22

Quote:Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.

Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?

Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.

Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.

Mr Mrdak : Yes.

Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.

Mr Mrdak : We will come back to you on that.

Bizarrely, even the question was addressed to Murky, the DF QON was answered by the ATSB:

Quote:Answer:

One of the principal safety improvement outputs of an ATSB investigation is the
identification of ‘safety issues’. Safety issues are directed to a specific organisation. They are
intended to draw attention to specific areas where action should or could be taken to improve
safety. This includes safety issues that indicate where action could be taken by CASA to
change regulatory provisions.

The ATSB encourages relevant parties to take safety action in response to safety issues
during an investigation. Those relevant parties are generally best placed to determine the
most effective way to address a particular safety issue. In many cases, the action taken during
the course of an investigation is sufficient to address the issue and the ATSB sets this out
clearly in its final report of an investigation.

Where the ATSB is not satisfied that sufficient action has been taken or where proposed
safety action is incomplete, the investigation report will record the safety issue as remaining
open. In addition, if the issue is significant and action is inadequate, the ATSB will make a
recommendation, to which the relevant party is required to respond within 90 days.

The ATSB monitors all safety issues (including all associated recommendations) until action
is complete or it is clear that no further action is intended. At this point, the issue will be

What followed after that of course was the Senate AAI (PelAir) inquiry that culminated in what was reportedly one of the most informative and incisive aviation related Senate reports delivered by the Senate RRAT Committee...

However I want to come back to this particular slice of Swiss Cheese:


Hansard ref: https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;db=COMMITTEES;id=committees%2Fcommsen%2Fe3895b3e-2fbd-4fd1-8891-2a174b03844b%2F0001;query=Id%3A%22committees%2Fcommsen%2Fe3895b3e-2fbd-4fd1-8891-2a174b03844b%2F0000%22

Quote:Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.

We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?

Mr Harfield : That is a correct assumption.

Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?

Mr Harfield : That is a fair assumption.

Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?

Mr Harfield : In this case I do not recall and I do not think that they did.

Which brings me to that slice of Swiss Cheese which eventually informed the committee to generate  recommendation 22 and this Govt response:



Yet here we are nearly 10 years after the Senate AAI report was tabled in Parliament and there is much evidence that particular Fawcett and Committee identified hole in the (now very moldy) slice of Swiss Cheese is still yet to be appropriately plugged??

Example reference QF28: Dots-n-dashes to: "How many minutes to bingo fuel??" 

And today: Descent below minima landing incident highlights importance of operator risk controls for unforecast weather

Finally and considering we are a decade on from the disturbing findings of the Senate AAI Inquiry which was largely endeavoring to improve the performance and transparency of both our recognised ICAO Annex 13 Aviation Accident Investigator and to a certain extent CASA. I would suggest that those endeavours have miserably failed...

Ref: Proof of ATSB delays and ICAO Annex 13 non-compliance??

Hmm...and where is Senator David Fawcett now?? 

MTF...P2 

PS: As an aside the Senate Committee are not the only one's to have failed to effect any positive reform  within the ATSB. In the thread link above, take note of the number of outstanding 'Short' investigations that go back over 2.5 years and then consider this 2019 ANAO recommendation to the ATSB:

Quote:Recommendation no.1

Paragraph 2.8

The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 05-13-2023

REPCON RA2021-00038

The following is an excellently well written REPCON, that IMO perfectly highlights how the system is supposed to work in order to close safety loops:   

Ref: https://www.atsb.gov.au/repcon/2023/ra2021-00038

Quote:Reporter's deidentified concern

Multiple reporters approached the ATSB with concerns regarding loss of control incidents involving AW139s operated by search and rescue (SAR) operators, crewed with single pilots utilising night vision goggles (NVG).

The reporters collectively state that single pilot SAR and Emergency Medical Service (EMS) NVG operations began in Australia as a way to allow aircraft operators to conduct their existing operations (mainly night out-landings and winching during low-visibility conditions), in a safer manner than under previous Nightsun operations/exemptions.

Conducting single pilot NVG operations for out-landings is in line with other jurisdictions. However, the Australian SAR/EMS NVG single pilot role has expanded to include advanced low-level operations, searching, advanced winching, vessel winching and low visibility operations. These operations are frequently being conducted as emergency situations in poor useable cue environments (UCE) due to the tasking priority and task approval by the contracting agency. The heightened risks of single pilot NVG operations are outlined in multiple research papers, regulator guidance and past incident and accident reports.

The reporters collectively state that the Australian industry’s liberal interpretation of the mandatory second occupant, has allowed aircrew officers (ACO) to operate from the cabin during NVG winching operations. One reporter stated that when the ACO is in the rear cabin, their attention is required on other critical duties and is no longer focused on the cockpit. In the winching phase, the full attention of the ACO is required on exactly that, resulting in the pilot being left with degraded or no cockpit support at the time of highest risk, when they would benefit from it most (ATSB investigation AO-2018-039). Conversely, if the pilot has any expectation of help or crosscheck from the ACO, it may exacerbate a situation when it is not forthcoming, as highlighted in ATSB investigation AO-2016-160.

The reporters believe that Australia continues to base the SAR night winching crewing model from a time when smaller, performance limited helicopters, that could not accommodate multi-crew, were used. This is no longer the case in the era of AW139s, which is an aircraft that is designed for, and mostly operated by multi-crew. Australia’s crewing model and mission profiles are outside global norms, best practice, and beyond the intention of CASA regulations and the rotorcraft manufacturer’s certifications.

All the reporters believe that even non-complex night SAR operations utilising NVGs is at the upper end of pilot cognition, regardless of single pilot experience or training.

The pilot may be required to plan an unscheduled approach at any time throughout the night, to a remote, unfamiliar scene, often with uneven terrain. The pilot must take into account associated winds, groundspeed, vortex ring considerations, turbulence and degraded NVG vision considerations, while alternating their visual scan from inside the cockpit to outside. The pilot is required to manage winching, the person on the cable below the helicopter, the visual reference and the instrument scan at the same time, while considering a departure plan. The pilot is also expected to have the capacity to deal with abnormal events without reaching task saturation.

The Christopher Wickens model recognizes that the human brain has limited processing capacity, and if overloaded with inputs, the attentional resources allocated to the various mental operations needed to effectively perform a task will significantly diminish.

One reporter provided an example of the winch emergency process at night for a winch runaway, approved by many operators, where the single pilot in the hover has to take their eyes off their external reference and instruments, to look inside and locate a switch on the centre console to turn off the winch at the ACO’s command. This process can take up to 45 seconds, during which the pilot’s attention is taken away from already demanding simultaneous visual and instrument scans, to locate the switch, while experiencing no depth perception, no peripheral vision, reduced field of view and a higher cognitive load for the operation overall. The reporter states they have observed this process resulting in loss of altitude and drift on multiple occasions. This is supported by Wickens & McCarley (2008) who stated that while searching outside for cues, changes on instruments can be missed. These missed changes can lead a pilot to believe that their knowledge of their position and trajectory in space is accurate.

Another reporter stated that in some cases, the best cues are on the left side and not able to be seen by the pilot in the right seat. Additionally, wind or obstacles may prevent turning to the better cues resulting in winch activities being conducted with sub-optimum cues. Wiggins et. al (2012) stated that pilots tend to underestimate the likelihood of loss of control and overestimate their ability to continue to control the aircraft if visual references are lost.

While tasking, fatigue, culture, weather, illumination and lighting may be contributing factors to loss of control incidents, the reporters believe that these are secondary to the primary safety issue. That is, the workload is too high and the flight control characteristics and control laws of the AW139 are too demanding for single pilot NVG winch operations. While this is partly the reality of the type of operation, it could be overcome if a pilot was in the left seat to affect the winch.

The reporters collectively agree that there is no way for a single pilot to cross check flight instrument parameters at a level of best practice for night operations without detracting from their primary scan of the outside environment. The ability to remain stationary and not drift in poor UCE is impossible, without very high order AFCS or alternative provision for drift cues (e.g. helmet mounted head-up displays). But these require significant training, proficiency, cost and procedural discipline. None of this is available on the current AW139 fleet in Australia, nor is it appropriate unless CASA were to pursue a construct of dedicated SAR aircraft with increased configuration requirements and pilot proficiency standards.

Manufacturer’s guidance

The Original Equipment Manufacturer (OEM) determined a two-crewing requirement for NVG operations, specifically, minimum crewing requirements of the AW139 Rotorcraft Flight Manual (RFM) Supplement 60, which states: ‘For single pilot operations (see Supplement 24 or Supplement 32 FAA Only): an additional, trained, crew member must be equipped with and use NVG’s during take-off and landing, on unimproved sites, to assist in obstacle identification and clearance.

One reporter believes that the RFM statement ‘..to assist in obstacle identification and clearance’ fails to highlight the additional protections of pilot monitoring and division of cockpit workload. The second occupant is not only intended for obstacle clearance and workload sharing, but for aircraft attitude monitoring and intervention (e.g. ‘Attitude … Attitude … ATTITUDE ..TAKING OVER’).

The reporter further states that the OEM is aware of the limitations of the AW139 for NVG winching operations, and also many pilots’ lack of understanding of the flight control characteristics. As such, the test report for single pilot NVG approval with an additional trained crew member was for surveyed airport to surveyed airport (including heliport) only.

The test report states that “it is conceivable that more complex operational tasks into unprepared locations would benefit from an ‘extra pair of eyes’ and assistance in operating more complex role equipment. Although arguably this is an issue that should be covered by the Operational Rules, the example given in MG16 of possible Flight Manual Supplement content represents a pragmatic approach to managing the interface between Operational and Airworthiness Rules”.

The reporter states that the lack of any testing by the OEM for single pilot night time winching operations indicates that the OEM did not intend for the aircraft to be used for single pilot NVG winching operations, nor is the OEM prepared to certify the aircraft for that operation and crewing model. Instead, the OEM has passed responsibility of risk controls for NVG winching operations to the relevant regulator.

The reporters believe that Australia, utilising the ACO in the rear cabin for night time winching operations, has been operating beyond the intention of the certification basis applied by the OEM and approved under EASA Part 29.

ATSB Comment

The ATSB made informal enquiries with multiple credible sources within industry, both in Australia and overseas, regarding the reporters concerns. It was evident from these enquiries that there are wide-ranging opinions within industry regarding the appropriateness of NVG winching risk controls and some of the reporters statements.

The ATSB also conducted a review of associated ongoing and closed ATSB investigations and the ATSB occurrence database.

That review, in combination with the industry feedback, provided sufficient reason to progress the reporters concerns through to CASA for comment.

To ensure transparency with industry, gain an understanding of any additional potential safety issues, and importantly, to ascertain if there were existing controls in place by operators to mitigate the risk(s), the full REPCON report was forwarded to the seven Australian operators who currently conduct single-pilot NVG operations in the AW139 for their information and comment. Five operators provided feedback.

The ATSB noted there are varying opinions regarding the technical suitability and intentions of the original equipment manufacturer (OEM) and CASA regulations for the conduct of single-pilot NVG winching operations in the AW139.

A review of the responses from Australian AW139 operators indicates that, while some operators are not opposed to a minimum two pilot requirement, others identified that an amendment to the crewing model had the potential to introduce new risks to these operations, such as:

• pressure to complete single-pilot tasks prior to last light
  
• crew resource management procedures and proficiency issues
  
• reduction in performance margins of the aircraft due to increased weight and/or payload limitations.
  

However, regardless of an operator’s position on the crewing model, all operators stated it is not the only risk control that should be considered for NVG winching operations.

All operators agreed that the patient risk assessments and subsequent tasking of aerial assets by the state based rescue coordination centres needs to be addressed. This concern has also been raised in several active ATSB investigations, and is being progressed separately through the ATSB REPCON process (RA2021-00074).

Most operators indicated that a poor UCE is an overarching factor in the serious incidents that have occurred during single-pilot NVG winching operations. Considerations for potential safety actions to mitigate the risks of operating in a reduced UCE included:

• Increased currency/recency requirements for operational crew.
  
• Review of procedures relating to restrictions due to location, weather and illumination.
  
• Enhanced training/procedures regarding multi-stage task assessments and decision-making.
  
• Use of the auto hover. Noting that one operator prohibits the use of the flight director hover (HOV) mode during over land winch operations, as their assessment is that the HOV mode may be used inappropriately to allow a pilot to hover when there are insufficient visual references to hover the aircraft manually; while another operator recognises that the auto-flight control system does not provide an adequate hover position in all conditions over land, but crews are well trained in the auto-hover and hover page Horizontal Stabiliser Indicator.
  
• All operators agree that additional high intensity searchlights need to be implemented to improve the UCE. However, some operators are concerned that unless this is a regulatory requirement, the cost of implementation would result in difficulties meeting contractual obligations.
  

All operators are supportive of an industry forum to further discuss the concerns raised above and contribute to the identification of appropriate risk controls associated with NVG winching operations.

Additionally, some operators have highlighted that a number of the incidents and broader concerns referred to in the REPCON are not isolated to the AW139. The REPCON reporters experience and knowledge is limited to the AW139 and the reporters intentions were to highlight what they consider safety issues in that rotorcraft, with a view that any safety outcomes would apply to the majority of single-pilot NVG operations. Their view, that would then set a precedent to review other aircraft types conducting the same operations.

The ATSB concurs that these concerns are not necessarily limited to the AW139, and noting the number of occurrences involving rotorcraft conducting a SAR/HEMS function that have had a deviation from safe flight in recent years, the ATSB suggests that the focus of the REPCON should be to identify risk controls in all helicopter types conducting single-pilot NVG winching operations.

In addition, industry could consider whether other (non-winching) single-pilot NVG operations in confined areas around complex terrain present similar risk profiles and would likely benefit from any safety actions that may result from this report.

The following ATSB investigations and occurrences are relevant to this REPCON:

AO-2021-022
AO-2021-018
AO-2021-010
AO-2020-038
AO-2020-031
AO-2018-039
AO-2016-160
AO-2011-166
ATSB Occurrence – 201906474
ATSB Occurrence - 201808484
ATSB Occurrence - 201704374
ATSB Occurrence – 201604008

The REPCON was referred to the regulator for information and comment.  Specifically, the ATSB requested CASA clarifies its interpretation of the AW139 RFM and the intentions of the current regulations relating to single-pilot NVG winching approval.

Regulator's response

CASA advised that they had previously sought clarification from Leonardo on the minimum crewing requirements for NVIS operations in the AW139. Leonardo provided a “No Technical Objection” to a NVG trained crew member in the aircraft cabin in order to satisfy the flight manual requirements. A copy of this correspondence was provided to the ATSB.  Noting the “No Technical Objection” does not specifically address the context of single pilot NVIS winching, and neither does the flight manual. In summary, while not specifically stated, the AW139 RFM does permit for single pilot NVG winching operations.

Providing that the RFM permits single pilot NVIS operations, CAO 82.6 does not prevent a single NVIS pilot and a NVIS aircrew member (winch operator) conducting NVIS winch operations or landing to a HLS NVIS basic. CASA’s intention is to transition the existing legislation into the Civil Aviation Safety Regulations and associated Manual of Standards. This will be achieved under CASA project OS13/19 which involves the transition of the existing NVIS legislation from CAO 82.6 to Part 91, Part 133 and Part 138 MOS’s.

In summary, while not specifically stated, the CASA regulations do allow for single pilot NVG winching operations. However, CASA considers the matters contained with the Repcon to be a valid safety concern and intends to discuss the Repcon at the earliest opportunity with Industry NVIS representatives.

The intended points for discussion at the NVIS TWG are as follows:

• Industry viewpoint on the spike in NVIS incidents
• Suitability of simulation for NVIS manipulative operations (confined areas and winch operations)
• Suitability of current NVIS recency requirements
• NVIS flight iterations for specialist skills i.e. winch, fast roping, fire operations etc
• Use of white light such as nitesun/trakka for winch operations
• Suitability of the AW139 for single pilot winch operations
• Suitability of other similar aircraft for NVIS winch operations
• NVIS winch techniques including – higher hover height for flyaway potential vs lower hover height for better hover reference

The intent is for CASA to seek feedback from industry NVIS operators relevant to the points raised within the Repcon and on other operational safety concerns.

CASA will then assess whether changes are necessary for NVIS minimum crewing requirements or whether requirements for NVIS training, ICUS, recency or in-flight activities are modified with the MOS and NVIS AC.

At time of publishing (August 2022), CASA has agreed to update the NVIS multi-part AC to include detailed information on the UCE and use of white light for situational awareness. Due to competing priorities, it is expected the amendment to the AC will be complete by late September 2022.

MTF...P2 

PS It is well worth going through the list of related ATSB investigations (above)

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 05-27-2023

Loss of control incident; -
or, just another FUBAR event;
or, lost in space;
or; resting between media engagements?

Where, Oh where has our Popinjay gone,
Oh where, Oh where can he be;
With his ego long and his IQ short'
Oh where, Oh where can he be;

Where, Oh where has our Popinjay gone,
Oh where, Oh where can he be;
With ideas so grand, and his media plan,
Oh where, Oh where can he be;

We did manage to capture a video short video of 'the team' in action; as you can see, they are far too busy to attend a boring session at the big house, dodging awkward questions – like WTD takes so long; or, why the sudden flurry of pointless reports; or, perhaps even supplying an answer as to why their continued existence, in current form is tenable – by any reasonable measure, given the evidence of past performances....? 

Toot – toot......

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 06-11-2023

IATA on State ICAO Annex 13 obligations; plus another NTSB v ATSB Chalk & Cheese event?? - 

Via IATA: https://www.iata.org/en/pressroom/2023-releases/2023-06-05-07/

Quote:Date: 5 June 2023

IATA Urges States to Provide Timely, Thorough and Public Accident Reports




Istanbul -The International Air Transport Association called on governments to live up to longstanding international treaty obligations to publish timely and thorough aviation accident reports. Safety is aviation’s highest priority.

Failure to publish prompt and complete accident investigation reports deprives operators, equipment manufacturers, regulators, infrastructure providers and other concerned stakeholders of critical information that could make flying even safer.

“The accident investigation process is one of our most important learning tools when building global safety standards. But to learn from an accident, we need reports that are complete, accessible and timely,” said Willie Walsh, IATA’s Director General.

The requirements of the Convention of International Civil Aviation (Chicago Convention) Annex 13 are clear. States in charge of an accident investigation must:

• Submit a preliminary report to the International Civil Aviation Organization (ICAO) within 30 days of the accident
  
• Publish the final report, that is publicly available, as soon as possible and within 12 months of the accident.
  
• Publish interim statements annually should a final report not be possible within 12 months.
  

Only 96 of the 214 accident investigations during the period 2018-2022 conform with the requirements of the Chicago Convention. Just 31 reports were published in less than one year of the accident with the majority (58) taking between 1–3 years. In addition to the fact that final reports regularly take more than a year, interim statements often provide little more than what was presented in the preliminary report.

“Over the past five years, fewer than half of the required accident reports meet the standards for thoroughness and timeliness. This is an inexcusable violation of requirements stated clearly in the Chicago Convention. As an industry we must raise our voice to governments in defense of the accident investigation process enshrined in Annex 13. And we count on ICAO to remind states that the publication of a complete accident report is not optional, it is an obligation under Annex 13 of the Chicago Convention,” said Walsh.

Next via the NTSB YouTube channel:

Quote:577 views  Jun 6, 2023

Full Session.  On May 23, 2023 Chair Jennifer Homendy hosted a roundtable discussion of safety experts from the aviation industry, labor, and government to discuss the current state of the runway incursion problem and possible solutions and next steps.

You don't have to watch anymore than the first 30 minutes to get a sense of the serious aviation safety credentials of the participants of this NTSB organised roundtable. That and their obvious combined commitment to proactively contribute to helping to provide solutions to the very real safety risk of runway incursions to the aviation industry. Kind of like what you would expect from a State's adoption of the principles of ICAO Annex 19 and it's establishment of a SSP (State Safety Program)...  

Compare that to this latest piffle from Popinjay HQ: No.43 from the list completed??

Quote:R44 pilot unable to recover from unanticipated yaw prior to Forresters Beach accident

Back to top

A NSW Central Coast helicopter accident highlights to pilots the need to be cognisant of factors that can induce unanticipated yaw, according to an Australian Transport Safety Bureau investigation report.

On 19 November 2022, the pilot of a Robinson R44 was conducting a private flight with two passengers to a function centre at Forresters Beach from a nearby property.

During the approach to the planned landing site, a carpark beside the venue, the pilot reported experiencing an uncommanded yaw to the right, which was unable to be recovered.

“During the approach to the confined carpark landing site, the helicopter experienced an unanticipated yaw to the right,” ATSB Director Transport Safety Stuart Macleod said.

“The pilot’s response was ineffective at recovering control – however the unanticipated yaw may have occurred at a height from which control of the helicopter was not recoverable.”

The helicopter subsequently struck powerlines before impacting the ground. While the helicopter was substantially damaged, fortunately the occupants received only minor injuries.

Considering Gosford weather observations of a north-east wind at 10 kt, the approach track placed the wind from a direction and at a speed known to be conducive to the onset of unanticipated yaw, the investigation notes.

“It’s important for helicopter pilots to remain cognisant of the factors that can induce unanticipated yaw, especially the relative wind direction,” Mr Macleod said.

“These factors should be avoided, or their influence on the helicopter’s anti-torque system should be managed through positive control of the yaw rate. Depending on the yaw rate recovery may not be immediate, but maintaining the recovery control inputs is the most effective way to stop the yaw.”

Read the report: Collision with terrain involving Robinson R44, registration VH-TKI, at Forresters Beach on 19 November 2022

 
MTF...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 10-31-2023

Closing the VFR into IMC safety loop - Live killer still lurks?? 

In light of the recent spate of GA/Recreational private pilot fatal accidents CASA put out the following very sobering Youtube video:


Hitting the timewarp switch I refer you to this post from "K" in April 2020: Fraught with peril – however....

Interesting, that on this same page, this pic featured...



Which brings me to a different but related safety loop, Clinton McKenzie produced this lengthy but (IMO) essential reading post on the UP:

Quote:ADS-B IN – A different perspective on the recent hype

My attention was recently drawn to a rather curious post by the ATSB on LinkedIn, about the ASD-B rebate. The post says:

Quote:We’re joining with the Australian Maritime Safety Authority in encouraging general and recreational aircraft owners to take advantage of the government’s Automatic Dependent Surveillance Broadcast (ADS-B) rebate program before it closes on 31 May next year.

- the STCA was designed as an alert for a breakdown in separation standards

- there was no set separation standard in non-controlled airspace

- the pilots were responsible for their own separation

they decided that a safety alert or traffic avoidance advice was not required, and cleared the aural alert.

The equipment on the two IFR aircraft generated what the air navigation service system construed as “nuisance” alerts – “an alert which is correctly generated according to the defined STCA system parameters (rule set), but is considered operationally inappropriate by the controller” - discussed further in the ATSB report. Many people were – and remain – astonished and appalled at that outcome.

Many of those alerts would not be construed as “nuisances” and dismissed as such if they occurred in airspace with separation standards. But changing the airspace arrangements around places like Mangalore and Ballina and… would create “nuisances” of a different kind: The airspace regulator would have to make those changes and the air navigation service provider have to employ more controllers.

Problem: What to do to shift the focus away from inadequate air navigation services and airspace arrangements, so as not to upset that status quo, while doing something that seems to address the risk of another IFR/IFR mid-air collision?

Solution: Encourage everyone to get ADS-B IN.

That way, Airservices is under less pressure to provide better or more services, ATSB continues to get all the data to help explain, in three dimensional graphic detail, the track to the smoking hole and AMSA continues to get all the data to better “affect” - I think the correct word in the context of ATSB’s statement is “effect” - a rescue if anyone survives. Meanwhile, the aviation safety and airspace regulator – CASA keeps its lips pursed and avoids eye contact. A new cockpit gizmo, subsidised by someone else, is an excellent solution for all the agencies concerned. Pats on the back all round!

VFR pilots should make no mistake: Our biggest risk - aside from inadvertent entry into IMC or fuel exhaustion or starvation - arises from being ‘heads down’ in the cockpit rather than keeping a proper lookout. There are of course visibility limitations created by airframe structures of every aircraft and the relative locations of other aircraft in flight. But it’s certain a pilot’s not going to see anything anywhere outside the aircraft while ever the pilot’s focusing on a gizmo in the cockpit and making the assumption it’s a source of traffic truth.

Assumptions about the absence of conflicting returns on a ADS-B IN system display and silence on the radio can lead to a dangerous false sense of safety. Just as there are plenty of explanations for silence on the radio, only one of which is the absence of other aircraft in the vicinity, there are plenty of explanations for no ADS-B IN system returns, or inaccurate information, on an ADS-B IN display. (Most of the traffic based at my local aerodrome involves aircraft that have no ADS or SSR transponder - at least none that’s switched on - whose pilots are best described as ‘taciturn’.)

There are plenty of examples of VFR pilots seeing an ADS-B IN return on their EFB and using that information to see and avoid - or mutually arrange separation from - another aircraft. And there are plenty of examples of IFR aircraft seeing VFR ADS information and doing the same. And that’s a great outcome. But those pilots don’t know what traffic wasn’t displayed accurately or at all in their cockpits at the time. There is no guarantee that all traffic in the vicinity will ever be displayed by ADS-B IN systems. And as with any other aircraft system, you have to know what the specific ADS-B IN system you’re using can do, how to get it to do what it can do and how to confirm it's actually doing what you assume and hope it’s doing, and that means understanding the system’s failure modes.

For all those reasons and more, I consider this to be an overstatement by ATSB:

Quote:To support its investigation into the [Mangalore] mid-air collision, the ATSB initiated an aircraft performance and cockpit visibility study to determine when each aircraft may have been visible to the pilots of the other aircraft. The study clearly showed that had the aircraft been equipped with ADS-B IN, the pilots would have been assisted in locating the other aircraft and alerted to its position much earlier than by visual acquisition.

There are lots of “ifs” missing from that sentence and the ATSB’s categorical “would have” conclusion. Both the Otter and Beaver in the Alaska tragedy were equipped with ADS-B IN but that didn’t result in either pilot comprehending the location of the other’s aircraft into which they collided.

The ATSB went on to say:

Quote:Both a cockpit display of traffic information with an ADS-B traffic alerting system or an electronic conspicuity device connected to an electronic flight bag application could have provided this advance warning of a potential collision to the pilots of both aircraft with this tragic accident probably being avoided.

Could have. If. Probably. The Beaver in the Alaska tragedy was carrying an EFB with a traffic alerting system. It didn’t work in the case of the Otter because the Otter was, unknown to its pilot and previous pilots, not broadcasting pressure altitude information. The Otter had traffic alerting capability, too. Until it was removed.

The equipment actually fitted to the Mangalore aircraft in compliance with regulatory requirements actually ‘triggered’ Short Term Conflict Alerts in the air navigation service system. Another description of those alerts is “advance warning of a potential collision”. That’s the verypurpose of STCAs. And the pilots of the aircraft probably assumed – reasonably I would suggest, given all of the safety hype around the original ADS-B mandate – that the air navigation service system would pass on those warnings rather than being justified in unilaterally dismissing them. Perhaps the tragic accident would have also been avoided if IFR pilots had clearly understood what a dangerously invalid assumption they were making about what the new ADS-B system was going to do for them.

On the subject of cockpit gizmos, there is one which is very cheap, very reliable, very accurate and almost pilot-proof: A modern carbon monoxide detector.

I mention carbon monoxide detectors because of the NSW Coroner’s Court inquiry and findings in the wake of the tragedy in which seven lives were lost in the Beaver accident at Jerusalem Bay in Sydney in 2017. One of the useful (and disturbing) things a modern CO detector will show you is the high level of CO to which we’re often exposed while just taxiing around on the ground (or water) in ‘ordinary’, serviceable aircraft. It will also help you to work out what to do with vents and windows to reduce the levels of exposure. Many of you will be blissfully unaware of the extent of your on-ground exposure and CASA remains wilfully blind to it, relying instead on reports from LAMES about defects found during maintenance and waiting for more CO exposure-caused fatalities and injuries.

In the course of the Coronial inquiry CASA was asked, in effect, how many more fatalities it would take before CO detectors would be mandated. According the Coroner, the CASA witness “frankly acknowledged”:

Quote:To be honest I'd say it would take probably unfortunately a number of accidents, hopefully not fatal, to trigger the risk level to be in the range where regulatory action would be required.

Translation: Affordable safety. CASA has decided that the value of lives potentially saved by mandating CO detection equipment is not sufficient to justify the mandate.

The evidence given by CASA was to the effect that there are approximately 8,365 single piston engine aircraft in operation in Australia and that dash-mounted CO detectors cost about $1,200. (Let’s set aside the fact that there are much cheaper options that are just as reliable and accurate, and include aural and visual alerts, as some panel mounted versions – remember how long it took to get rid of the fixed ELT mandate and how long it took for EFBs to be accepted by the regulator?) On CASA’s figures that’s about $10,000,000 to fit the single piston engine fleet. So, that means CASA reckons it’s not worthwhile spending $10,000,000 on CO detectors until the further body count makes it worthwhile.

In contrast, to justify CASA’s regulatory response in the wake of the Angel Flight tragedies involving a total of six fatalities (one near Nhill in 2011 the other near Mt Gambier in 2017), Dr Aleck of CASA said:

Quote:Our objective here is not to specifically address what caused those two accidents; it's to address what kinds of things can cause incidents and accidents of this kind. We're being prospective. If we were to wait for sufficiently robust data to support an evidence-based decision for every individual decision we took in this space, we would have to wait for a dozen or more accidents to occur.

When asked by the Angel Flight CEO as to why CASA had chosen to by-pass the usual protocols for regulatory change, the then CEO of CASA said:

Quote:I have the power; because it’s easy.

Why was CASA “prospective” rather than waiting for more accidents in the Angel Flight case, by-passing the usual regulatory change process, but is waiting for more fatalities and injuries in the case of CO detectors? Answer: The capricious consequences of politics. Pressure was put on CASA by the federal government to be seen to do something in the case of Angel Flight and, sadly for the next victims of CO exposure, the Beaver tragedy barely raised a federal government eyebrow in the direction of CO detectors. That’s probably because of the time it took to work out that CO exposure was a factor in the tragedy.

Get ADS-B IN by all means. But don’t believe all the hype. It’s not a panacea for situational awareness or the intractable inadequacies in air navigation services and airspace arrangements.

Yours in aviation safety.

A bag of choccy frogs for that one CM...

MTF...P2 

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 11-01-2023

Popinjay to the rescue on ADSB for VFR aircraft?? - 

In follow up to CM's UP post (above), I note that yesterday Popinjay released yet another bollocks 'attributed to' media fluff piece...

Quote:Moorabbin near-collision further highlights the importance of ADS-B IN


In mid-October 2023, a Sling light sport aircraft and a Piper Cherokee operating in the Moorabbin training area, south-east of Melbourne came within 100 metres of each other while both aircraft were flying at the same altitude.

The crew of the Sling reported to the ATSB they observed seeing the Cherokee pass in front of their aircraft in close proximity. ADS-B data obtained by the ATSB confirmed the Sling crew’s report, as well as showing just how close both aircraft came to colliding mid-air.

Neither aircraft were equipped with ADS-B IN systems, and nor were they required to be. An ADS-B IN capability with a cockpit display or an electronic flight bag application showing traffic information can significantly enhance the situational awareness for a pilot, particularly when flying in non-controlled airspace.

“The ‘see and avoid’ principle for pilots has known limitations, 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,” ATSB Chief Commissioner Angus Mitchell said.

“When flying in non-controlled airspace it’s important to have a high level of situational awareness, and one tool that can help you and other pilots is ADS-B IN.”

To support its investigation into the mid-air collision of two IFR training aircraft near Mangalore Airport in February 2020, the ATSB initiated an aircraft performance and cockpit visibility study to determine when each aircraft may have been visible to the pilots of the other aircraft*. The study clearly showed that had the aircraft been equipped with ADS-B IN, the pilots would have been assisted in locating the other aircraft and alerted to its position much earlier than by visual acquisition.

In lieu of a formal transport safety investigation into the Moorabbin training area near-collision, the ATSB is using this occurrence to further encourage all eligible general and recreational aircraft owners and pilots to equip their aircraft with ADS-B OUT, and to strongly consider using ADS-B IN for enhanced situational awareness.

To incentivise voluntary uptake of ADS-B installations in Australian–registered aircraft operating under Visual Flight Rules (VFR), the government is providing a 50 per cent rebate on the purchase cost – capped to $5,000 – of eligible devices and, where applicable, the installation. While eligibility rests on equipment providing an ADS-B OUT capability, devices that provide ADS-B IN, as well as low-cost portable ADS-B devices, are also eligible for the grant.

If you have not already, and you are eligible, please take advantage of the generous rebate to equip your aircraft with ADS-B before the offer ends on 31 May 2024.

More information, including on how to apply for the rebate is available at: https://business.gov.au/grants-and-programs/automatic-dependent-surveillance-broadcast-rebate-program

* The image used in this news story is a still extracted from an animation created as part of the aircraft performance and cockpit visibility study.

Publication Date: 31/10/2023

Hmm...be interesting to see CM's response to that one?? -

MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 11-02-2023

Popinjay to the rescue on ADSB for VFR aircraft - Part II

Via the UP:

Quote:Clinton McKenzie

Another advertisement from the ATSB about ADS-B IN.

This time the advert has been triggered by a “near collision” between two VFR aircraft in the Moorabbin training area.

VFR aircraft.

In a Delta area.

The ATSB keeps dealing with this issue as if there are only ever ‘isolated pairs’ of aircraft. One Sling and one Piper Cherokee. One Seminole and one Travel Air.

If all the ‘ifs’ line up and there are just two aircraft in proximity, laterally, and the pilot of one or both aircraft ‘see’ and accurately interpret the traffic display of ADS-B IN at a glance down in the cockpit, great. But then there’s the common reality of busy airspace.



Which of the displayed aircraft, if any, is a collision risk to me on my track WAD - TWRN? (This is just a snapshot from the EFB provider supplied data, without my conspicuity device connected. Just assume they are ADS-B IN symbols in green.) You have the luxury of looking at a much bigger and stable display on your computer monitor.

(The latest ATSB advert includes a text box that says: “ATC Short Term Conflict Alert (STCA) between AEM and JQF.” Maybe Airservices should do in the Melbourne FIR what’s been done in the Brisbane FIR: Just turn off the SCTA functionality below 4,500’ so that ATC is not bothered by the nuisance.)

I finally note, again, that the Beaver and Otter in the Alaska tragedy were both fitted with ADS-B IN with all sorts of bells and whistles alerting capability … that wasn't functioning properly.

And from a AAI SME, via the AP email chains:

Quote:This is a legal minefield. Maybe they've been reading Clinton M’s work! The ATSB seem to be doing CASA’s sales job. I’ve never heard of any Accident Investigation Agency talking $$ for a deal, in-lieu of an investigation. Plus, I note the rebate offer of up to 50%, capped at $5,000 (to those eligible), ends on the 31 May 2024??? Is that when its ok to cease improving safety?? It seems odd, particularly under the ATSB banner.

Mangalore seemed like an effort to protect ATC, now we have “in-lieu of an investigation….” you can get rebated equipment - maybe steak knives too?  It seems like separation risk control is shifting from ATC to pilots. When you consider the funding of Onesky, the funding arrangements must be questioned.

VFR pilots in training areas are learning the skills of aviating and shouldn’t be spending time ‘heads-down’ whilst training. It may help pilots/instructors/ATC, but I can imagine what ADSB-IN would look like at an inbound point to busy GA airfield, ie Moorabbin or Bankstown.

I’m all for technology being used to improve things, but this should be based on a safety case and systemic investigation, not just dragging out the “Limitations of See and Avoid” BASI did about 30 years ago.

VFR training airfields will always have traffic issues. They have specific risks, when compared to the industry in general. Is this the right risk control for that environment?

There’d be plenty of data to support that.

I’m sure there’s more angles to this bizarre scenario. Betts needs to remind his people of their Acts and how the system is designed to work.

MTF? - I definitely think so...

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 11-04-2023

Popinjay/Kinley/Spence to the rescue on ADS-B for VFR aircraft?? -

Via the UP:

Quote:Clinton McKenzie

Another advertisement from the ATSB about ADS-B IN.

This time the advert has been triggered by a “near collision” between two VFR aircraft in the Moorabbin training area.

VFR aircraft.

In a Delta area.

The ATSB keeps dealing with this issue as if there are only ever ‘isolated pairs’ of aircraft. One Sling and one Piper Cherokee. One Seminole and one Travel Air.

If all the ‘ifs’ line up and there are just two aircraft in proximity, laterally, and the pilot of one or both aircraft ‘see’ and accurately interpret the traffic display of ADS-B IN at a glance down in the cockpit, great. But then there’s the common reality of busy airspace.



Which of the displayed aircraft, if any, is a collision risk to me on my track WAD - TWRN? (This is just a snapshot from the EFB provider supplied data, without my conspicuity device connected. Just assume they are ADS-B IN symbols in green.) You have the luxury of looking at a much bigger and stable display on your computer monitor.

(The latest ATSB advert includes a text box that says: “ATC Short Term Conflict Alert (STCA) between AEM and JQF.” Maybe Airservices should do in the Melbourne FIR what’s been done in the Brisbane FIR: Just turn off the SCTA functionality below 4,500’ so that ATC is not bothered by the nuisance.)

I finally note, again, that the Beaver and Otter in the Alaska tragedy were both fitted with ADS-B IN with all sorts of bells and whistles alerting capability … that wasn't functioning properly.

And from a AAI SME, via the AP email chains:

Quote:This is a legal minefield. Maybe they've been reading Clinton M’s work! The ATSB seem to be doing CASA’s sales job. I’ve never heard of any Accident Investigation Agency talking $$ for a deal, in-lieu of an investigation. Plus, I note the rebate offer of up to 50%, capped at $5,000 (to those eligible), ends on the 31 May 2024??? Is that when its ok to cease improving safety?? It seems odd, particularly under the ATSB banner.

Mangalore seemed like an effort to protect ATC, now we have “in-lieu of an investigation….” you can get rebated equipment - maybe steak knives too?  It seems like separation risk control is shifting from ATC to pilots. When you consider the funding of Onesky, the funding arrangements must be questioned.

VFR pilots in training areas are learning the skills of aviating and shouldn’t be spending time ‘heads-down’ whilst training. It may help pilots/instructors/ATC, but I can imagine what ADSB-IN would look like at an inbound point to busy GA airfield, ie Moorabbin or Bankstown.

I’m all for technology being used to improve things, but this should be based on a safety case and systemic investigation, not just dragging out the “Limitations of See and Avoid” BASI did about 30 years ago.

VFR training airfields will always have traffic issues. They have specific risks, when compared to the industry in general. Is this the right risk control for that environment?

There’d be plenty of data to support that.

I’m sure there’s more angles to this bizarre scenario. Betts needs to remind his people of their Acts and how the system is designed to work.

In addition to Popinjay's bizarre, totally inappropriate advertorial, I note that CASA and AMSA have backed up Popinjay with social media sharing of the advertorial, with additional comments:

Quote:Civil Aviation Safety Authority
48,294 followers
1d •

‘What benefits can ADS-B provide?

This recent post from the Australian Transport Safety Bureau provides an example of how it can significantly improve situational awareness for pilots.

Don’t forget to apply for the government’s 50% rebate on ADS-B devices.

Find out more: civilaviation.au/adsb

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Australian Maritime Safety Authority
23,473 followers
3d •

ADS-B data is a valuable tool used for search and rescue operations in Australia, which can help improve AMSA’s ability to locate aircraft in distress and save lives. It also helps to enhance safety of aircraft search and rescue operations.

If you’re a general or recreational aircraft owner, learn how you can take up the ADS-B rebate program to potentially improve search and rescue outcomes.

#searchandrescue #aircraft

Quote:Australian Transport Safety Bureau
20,415 followers
4d •

In mid-October 2023, a Sling light sport aircraft and a Piper Cherokee operating in the Moorabbin training area, south-east of Melbourne came within 100 metres of each other while both aircraft were flying at the same altitude.

The crew of the Sling reported to the ATSB they observed seeing the Cherokee pass in front of their aircraft in close proximity. ADS-B data obtained by the ATSB confirmed the Sling crew’s report, as well as showing just how close both aircraft came to colliding mid-air.

Neither aircraft were equipped with ADS-B IN systems, and nor were they required to be. An ADS-B IN capability with a cockpit display or an electronic flight bag application showing traffic information can significantly enhance the situational awareness for a pilot, particularly when flying in non-controlled airspace.

The ‘see and avoid’ principle for pilots has known limitations, 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.

To support our investigation into the mid-air collision of two IFR training aircraft near Mangalore Airport in February 2020, we initiated an aircraft performance and cockpit visibility study to determine when each aircraft may have been visible to the pilots of the other aircraft*. The study clearly showed that had the aircraft been equipped with ADS-B IN, the pilots would have been assisted in locating the other aircraft and alerted to its position much earlier than by visual acquisition.

In lieu of a formal transport safety investigation into the Moorabbin training area near-collision, we are using this occurrence to further encourage all eligible general and recreational aircraft owners and pilots to equip their aircraft with ADS-B OUT, and to strongly consider using ADS-B IN for enhanced situational awareness.

To incentivise voluntary uptake of ADS-B installations in Australian–registered aircraft operating under Visual Flight Rules (VFR), the government is providing a 50 per cent rebate on the purchase cost – capped to $5,000 – of eligible devices and, where applicable, the installation. While eligibility rests on equipment providing an ADS-B OUT capability, devices that provide ADS-B IN, as well as low-cost portable ADS-B devices, are also eligible for the grant.

If you have not already, and you are eligible, please take advantage of the generous rebate to equip your aircraft with ADS-B before the offer ends on 31 May 2024.

More information, including on how to apply for the rebate is available at: https://lnkd.in/dk5bN3kV

*The image used in this post is extracted from an animation created for the aircraft performance and cockpit visibility study: https://lnkd.in/gc8SJ3fw

Department of Infrastructure, Transport, Regional Development, Communications and the Arts

Note the above link to the Department proving that EWB is in on it...

However bizarrely no link or reference to Harfwit's crew at ASA, even though the ADS-B tracking information for the Moorabbin training area incident would have been provided by ASA and presumably triggered a STCA alert?

From AO-2020-012 final report:

Quote:"..Because aircraft operate in non-controlled airspace, without published separation standards, it is not unusual for controllers to receive a short term conflict alerts (STCAs). Nuisance alerts, or alerts which need to be checked but very rarely responded to are of little benefit..."

I also wonder why the ADS-B record of the incident and the incident report itself have not been made publicly available to review? From my probing of the almost impenetrable ATSB occurrence database, this incident doesn't appear to have been recorded? see - HERE.

Very much related I note the following ISASI 'lessons learnt' paper: From see-and-avoid to detect-and-avoid:
Learnings from a mid-air collision investigation

Perhaps the passage under the subtitle 'Detect and Avoid' explains the rationale for the strong support of the ATSB advertorial?

Quote:The ATSB encourages the fitment of ADS-B transmitting and receiving devices in all aircraft. The technology not only provides for enhanced situational awareness to assist in self-separation outside controlled airspace; but also provides ATC with more accurate information on aircraft movements both within and outside controlled airspace. In Australia, ADS-B data is also accessed by rescue coordination centres, to assist in locating aircraft accidents, particularly in remote areas; and investigative agencies including the ATSB to assist with investigations.

Currently all IFR aircraft operating within, or in and out of, Australia are required to be equipped with ADS-B transmitting equipment (ADS-B OUT). Additionally, some VFR aircraft, depending on their operational location and the type of operation, are required to be fitted with ADS-B transmitting equipment. There are currently no requirements for any aircraft operating in Australia to be equipped with ADS-B IN. There is currently no information available on the number of IFR aircraft in Australia that are fitted with ADS-B IN devices, however Australia’s Civil Aviation Safety Authority (CASA) recently published data on equipment fitted in VFR aircraft including ADS-B IN. The study found that in 2020, approximately 15-18% of VFR general aviation aircraft were equipped with an ADS-B IN system.

The study also found that approximately 90% of general aviation VFR pilots use some form of electronic flight bag application (EFB) to support their operations. With the introduction of low cost electronic conspicuity devices that can both transmit and receive ADS-B information, all of these pilots can have access to up to date ADS-B information about the aircraft local to them without needing to go to the expense of a full ADS-B IN system. These devices can also provide IFR aircraft that are already equipped with ADS-B OUT, with an ADS-B IN capability. Electronic conspicuity devices capable of either ADS-B IN only or with the transmitting functionality disabled can be used in
IFR aircraft to provide the pilot with ADS-B IN information without the cost of having new system installed.

While effective, these devices paired with EFB applications do not necessarily provide the full functionality of hard-wired ADS-B IN systems and must be correctly setup and configured to work effectively.

To encourage the take up of ADS-B technology both transmitting and receiving amongst VFR pilots the Australian Government opened a rebate scheme in July 2022. This scheme provided a 50% rebate, up to $5,000, on the purchase an installation of ADS-B devices for VFR aircraft. The rebate scheme included the purchase of electronic conspicuity devices to connect to electronic flight bag applications.

It must be noted that having an ADS-B IN display in an aircraft does not change a pilot’s responsibility to communicate to other aircraft via the appropriate radio frequency. These systems should not be used to make traffic avoidance decisions on their own, but rather as an additional source of accurate information for pilots to use when making arrangements with other pilots.

However perhaps the real truth, of the Popinjay bizarre advertorial, lies in the paragraphs that follow under the subtitle 'The Future':

Quote:The future

Despite the known limitations of the ‘see and avoid’ concept, including those demonstrated with this accident, it has been used effectively for a long time. However, the basic premise relies on the pilot of the aircraft viewing the environment around them and using radio calls to build situational awareness to identify other aircraft in the vicinity. However, the uptake of remotely piloted or uncrewed aircraft systems (RPAS or UAS) is beginning to challenge this as we are seeing more aircraft operating without a pilot onboard to use visual acquisition.

This is not a problem when the RPAS or UAS are small and operating within line of sight of the pilot who can also see other airborne traffic and manoeuvre to ensure separation. However, we are now seeing larger and higher performance RPAS and UAS operating in many different environments, at higher altitudes and beyond line of sight of the pilot operating them.

Currently in Australia there are several techniques used to ensure effective separation of crewed and uncrewed aircraft. The most common ones are segregated airspace, setting up temporary restricted or danger areas for the operation, putting in place NOTAMS to advise other airspace users of the operation, or the RPA pilots using ADS-B IN technology to assist them in locating other aircraft. However, in Australia without a special permission RPAS are not allowed to transmit ADS-B information to the aircraft around them.

The development of effective techniques to allow RPAS to ‘see and avoid’ other aircraft is currently ongoing and there are multiple systems that are using cameras and other sensors to assist RPAS to locate other aircraft. However, as with the human eye relying on cameras and sensors to detect other aircraft is not always a foolproof solution as with the human eye visible light cameras cannot see through cloud, heat sensors may incorrectly detect birds as threat, or a flock of birds may simply overcome the computers processing power to allow for effective avoidance. Furthermore, these techniques do not alert the pilots operating other aircraft around the RPAS about the hazard.

ADS-B technology can overcome many of these issues. If both the RPAS and the crewed aircraft are transmitting and receiving position information, they can know the type of aircraft and where it is well before it becomes a threat. Not only does this assist in collision avoidance but it reduces workload on agencies not having to segregate airspace or issue NOTAMS.

Soon the effective integration of RPAS and UAS into the airspace system around the world is going to be a necessity. ‘Detect and avoid' is, by necessity, going to have to replace ‘see and avoid’ as the main method by which aircraft and pilots ensure self-separation in airspace where ATC does not provide a separation service. Whether this is using ADS-B or a similar technology remains to be seen, but the mid-air collision at Mangalore demonstrated the limitations of ‘see and avoid’ as a risk control, and the ATSB simulation of both the cockpit view and the ADS-B technology shows how ‘detect and avoid’ will be a key piece of effective airspace management for both crewed and uncrewed aircraft well into the future.

The explosion of RPAS/UAV operations inside CTA in an already overburdened, understaffed and outdated ATC system, if not properly managed, certainly has the potential for disaster. However to state that the fitment of ADS-B would provide an enhancement of situational awareness for VFR aircraft operating inside a designated training area is beyond all reality and perhaps highlights how endemic AIOS ("acquired institutionalised ostrichitis syndrome") has become underneath the Canberra bubble??

MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - ventus45 - 11-04-2023

Endemic AIOS is fast becoming pandemic.

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RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 11-09-2023

CM & CO burst the bubble on Popinjay/Kinley/Spence ADS-B advertorial! -

Via the UP:

Quote:Clinton McKenzie

Inbound to YMMB.

Ready…Setty…Stare!


Remember: You’ll be looking at a small display in a cockpit being rattled around by turbulence.

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Squawk7700

I feel like Rainman looking at that pic and can see 3 or possibly 4 conflicts.

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Clinton McKenzie

Well done! All you need to do is keep staring at that screen and your situational awareness task is done. The completeness and accuracy of the displayed traffic data is guaranteed!

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ER_BN

Clinton,

Thanks for the inbound YMMB graphic, I've passed it onto someone far more qualified to comment than me, but the display and the associated irony of the MNG tragedy is noted.

RE: The MNG accident, seeing the ATSB investigation was just bumptious hubris and incompetence does anyone know when the coroner's inquiry is?

You mentioned 4 STCAs, perhaps it was my failure in reading the report properly but I could only see two re JQF and AEM? The initial and a re-alert.

It would be my understanding that after the first STCA was acknowledged by the controller, the STCA acronym remained constantly in both the aircrafts' track labels on the Air Situation Display until collision.

At a time before the collision the STCA re-alerted (that does not invalidate the previous sentence) but the derelict ATSB investigation never explained the reactivation.

There are a huge number of shortcomings in the report and I can sympathise with many pilots and controllers who have mentioned the word "cover-up".

When confronted with CONSPIRACY or INCOMPTENCE, I am an incompetence person myself as I think we reached "peak human" long ago.

That doesn't mean self interest, greed or snouts in the trough haven't played a part in decision making in AsA, CASA or ATSB.

Given the Senate Estimates are just a joke, I have sent off info to the NACC, though given the state of the Australia and the reported number in the NACC inbox, no doubt it's a far queue.

At least Lead Balloon can smile given that by all their comments in the MNG reports and their associated simplistic distraction of ADSB-IN, ATSB by implication if not by statement has declared CLASS G is safer for VFRs than IFRs. I have to laugh when Australian controllers issue traffic "alerts" VFR to VFR in G. The phrase "Get your hand off it" comes to mind. Sort out your IFR to IFR first. More surveillance has led to laziness in the whole process.

I honestly believe without surveillance (Radar or ATSB) and with FIS still existing MNG would not have happened.

Where's FSO Griffo when you need him...What, in OAP luxury at Mar a Lago....Half his luck!!

Australia - Centre of Excellence only in Mediocrity.

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Clinton McKenzie

Re STCA’s, I’ve revisited the ATSB Report on the Mangalore tragedy. It says, with my bolding added:

Quote:In the time between JQF taking off and the collision, there were three STCA alerts generated.

…

On the basis of analysis conducted by an ATC subject matter expert and technical detail provided by Airservices, it was assessed that:

The first STCA, at 1122:42, was a nuisance alert generated by JQF conflicting with VFR traffic in the Mangalore circuit area.

A second STCA, at 1122:49, occurred as the controller passed traffic information to JQF (Figure 13). At that stage, indications were that the aircraft would pass abeam each other. The STCA was assessed by the controller but not cleared from the screen at this point.

The controller re-inspected the two aircraft at 1123:30 after JQF had turned towards the planned outbound track. The velocity vectors indicated that lateral displacement would be maintained, with JQF passing behind AEM in about one minute. At that time, the controller’s display showed AEM at 4,800 ft while JQF was at 3,400ft.

A final STCA alert occurred at 1123:51. The controller zoomed in to inspect the aircraft flight paths and altitudes again and acknowledged the STCA at 1124:09. The controller identified that JQF was going to pass across the track of AEM, but at that time, 11 seconds prior to the collision, indications on the controller’s display showed AEM at 4,500 ft and JQF at 4,000 ft, with 0.9 NM lateral separation between the aircraft.

So I’ll correct my ‘4’ to ‘3’ (though I’m still digging to find the provenance of my original ‘4’).

Perhaps your ‘2’ comes from Figure 13, described as “Recreation of STCA display at 1122:49”, which shows only 2 STCA ‘boxes’?

Of course, a recreation of the circumstances at 1122:49 excludes the “final STCA” which “occurred at 1123:51”. It’s very hard for me to fathom the logic behind the ATSB’s decision not to include the closest STCA in time to the collision in the recreation of the STCA display. The ATSB went to the trouble of recreating the display showing the velocity vectors as not intersecting at the time of the 1122:49 STCA but decided not to recreate the display showing the velocity vectors at the time of the STCA immediately preceding the collision. Go figure.

Of course, all of this is OK for IFR aircraft because there is no separation standard in non-controlled airspace. Meanwhile, some VFR pilot has an attack of the vapours after seeing another aircraft in close proximity in a published flying training Delta, and the ATSB uses that as basis for another advert for ADS-B IN, which advert included a recreation of the STCA. Go figure.

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missy

Quote:Originally Posted by Clinton McKenzie
The real answer to missy's question is the one of which I suspect missy is aware

Nope, I'm not sure that I do, divergent procedures either sides of on arbitrary line on a map that arcs 50miles north of Sydney and across the continent. National standardisation? Oversight by CASA?Periodic investigations by ATSB?
Probably a corporate history somewhere, someone would know but I do wonder who the BN Centre manager was who authorised the change? Who was the Safety Manager at the time? Who was the ATC GM or Head ATC at the time? Wouldn't the controller Union ( Civil Air ) raise an objection?

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ER_BN

Clinton,

Thanks for your prompt clarification.

The STCA system by its very nature works on conflict pairs and in my previous post I noted I was referring to those STCAs specifically regarding the JQF/AEM pair.

As far as I can tell that is what the ATSB report indicates so we are in agreement.

Not sure what you meant by Perhaps your ‘2’ comes from Figure 13, described as “Recreation of STCA display at 1122:49”, which shows only 2 STCA ‘boxes’?
For tracks under the jurisdiction of the controller, the yellow "box" around the track labels of the two relevant aircraft is part of the TAAATS Eurocat Human Interface (HMI) to highlight the two aircraft and is yet to be acknowledged by the controller. 1 STCA in the circumstances of the MNG accident correctly produces 2 "boxes".

No one should assume that any ATSB graphical "re-creation" accurately aligns with what the controller saw on the TAAATS Eurocat Human Machine Interface.

My feedback to controllers at the time was that the STCA HMI would be displayed from 1122:49 to collision.

On the assumption that this is correct, the ATSB never explains why the STCA system changed the STCA HMI on JQF and AEM's track labels from Acknowledged status back to Unacknowledged status at 1123:51.

It would have been one of the first things I would have determined as part of the technical investigation, and I have done more than one hundred of them.

I have no idea whether that is what really happened or was displayed to the controller. Problems with TAAATS Eurocat Replay! That's the rhinoceros in the room!

And we haven't yet mentioned the elephant or the hippopotamus in the room either!

All this could be viewed as farcical but four humans died...

Do you think a GA pilot organisation might ask when the Coroner's Inquiry is going to happen?

Or are we happy that the memory of the 4 pilots is tainted by an inaccurate and incomplete ATSB report?

If you want to talk, PM me and I will call.

Have a good one!

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PiperCameron

Quote:Originally Posted by Clinton McKenzie
Well done! All you need to do is keep staring at that screen and your situational awareness task is done. The completeness and accuracy of the displayed traffic data is guaranteed!

Exactly. You've just missed the non-ADSB equipped aircraft in the mix... me!!

It probably seems busy to those unfamiliar with YMMB airspace and unaware there are two parallel runways in operation, but all I see looking at that pic is a normal busy day at Moorabbin, with the CAE-Oxford Cessnas doing their usual 3-mile circuits and the queue building at Carrum. As far as conflicts go, I have no idea where UUD is going, but then it's an LTF Sling (probably student solo) and you'd want to hope the other guy inbound has him in sight. Situation Normal.

Suffice to say, the YMMB Tower Controllers do an amazing job keeping the kiddies in line day-in day-out.

MTF...P2

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 01-23-2024

Fair enough - me first...

OK; it was my idea after all, to summon up as wide a range of 'experience' and 'operational savvy' to at least attempt to find a solution to the VMC qualified pilot coming to grief (or hot water) in IMC. It is, world wide, a major problem; but not so much in lands where the weather is a lot less benevolent than the Australian 'norm'.

I intend, deliberately, not to add in the safety improvements auto pilot and GPS navigation afford; both require a 'training' and educational element which can be easily provided. The only remote problem I see is a complete dependence on these systems and the 'software' associated. As a fully paid up member of the 'old-school' philosophy applying to both Murphy's & Sods law of the sea; whilst enjoying (greatly) the luxuries provided, I am always - always of a mind set which verifies; first we try, then we trust. But enough said, for that is a different discussion.

“Of each particular thing ask: what is it in itself? What is its nature?”

VMC qualified entering IMC; is a risk, but quantifiable on a scale; a quick scamper over a high spot; or a slide through a valley; each time, the 'risk' needs to be evaluated. The quality of that 'evaluation' depends on several variable parameters; it is a 'skill': but that 'skill' is also dependent on many variables. But now I digress. Let us simply focus (for now) on the median of the most fatalities - Oh, what, there isn't one? Then let's begin, at the beginning; at the grass roots.

Restricted PPL. Let's have a 'candidate' (victim) - introducing Joe Average. So, happily through the basics of RPPL Joe wants to stretch his wings - perhaps even has notions of acquiring professional status; but, at the moment the wide world outside the training area is 'verboten', he must learn to 'navigate'. More head scratching and 'book-working' but exams passed. So, now ready to apply the essential 'learning' to a practical purpose, i.e. go somewhere. But there are some minor road blocks to this ambition and here we encounter the first of 'things' which (IMO) are the root cause of many of the fatal accidents we encounter. Now we enter the realm of rigid requirement and again (IMO) the very place where the seeds are sown for many VMC pilots fatal events in IMC. In short, they have NDI of what they are actually looking at. Why? Well because they have never seen it before.......

The 'system' demands' they complete (say) five 'navigational' exercises of 'x' duration and etc. All laid out - boxes to tick. Now then; Joe turns up bright and early - gets the 'met' data; plans his route, etc.  and meets with his instructing pilot. Over a coffee they discuss and do that which is demanded- so far so good - BUT. The weather forecast looks 'sketchy' - maybe - maybe not. Other routes are in the same boat - so it looks like a 'no-go' for lesson one.

Why - well the costs are serious; and, importantly, the penalty for 'non completion' of Nav 1 is - do it again. So, the only chance 'Joe' has to learn about operating in 'sketchy' weather conditions is 'cancelled' - until the weather improves, Moorabbin Aviation Services (for example) charges are 'representative' and competitive; but they are a significant factor in the decision to 'go' or not go. So, to meet the 'requirement' Joe must wait for 'good conditions' to tick the Nav ! box.

Proposition. For educated consideration. What if:-
Joe turns up are the weather is 'marginal'. But, instead of a rigid requirement; the 'system' mandated a 'block' of - for sake of a 'number' say 20 hrs of 'navigational' experience? So now, Joe and instructor can 'toddle off' and see what the forecast was, in reality. Together, the instructor (in command) can 'teach' about the weather and assist Joe to make 'considered' decisions; Joe experiences, first hand, what the 'weather' really means to his desired destination and gains an appreciation of the manifold risks. All on his first 'Nav'. Food for thought and an appreciation of what 'sketchy' weather looks like and 'the options' and the 'traps'. In what should have been a two hour Nav exercise; Joe has, in the 1.2 hours gained 'hands on' real life experience, An experience which may, one day, spare him and his kids the death trap of 'no ducking idea'.

So, instead of a large bill for an uncompleted exercise; Joe toddles off with a credit of 1.2 hours off his 20 hour bill and he has learned some valuable lessons about 'weather flying'. Real experience. Even if the next 10 hours of 'dual' all ended up being a diversion and return to base due weather; so what. He has 'met-the-beast' and learned to beat it. My Granny with about two hours of instruction could find her way across Australia with only a road map. So what are we teaching student navigators? Only to tick the boxes and only fly in 'gin clear' skies. Ah; if it was always so. Sooner or later, one day, the average Joe is going to be confronted with weather 'not quite' as scripted. It is essential that they learn, from Nav 1 when to cut, when to run and when to find a friendly pub and call it quits for the day.

Proposal - Make it a 'block' of navigational experience for qualification; partly (mostly?) under instruction, to 'assist' with weather related decision making. Discard the iron clad, rigid system of 'x' number of 'exercises' - in the best weather conditions. Cost benefit - Yes. Experience benefit - priceless. Selah.

That, is my two bob's worth. Apologies for the long hand ramble; but the VMC pilot crashing in IMC is a serious statistic; expensive, heartbreaking and although never completely preventable; perhaps some 'out of the box' thinking could reduce that number. Look, I don't know - but FWIW;- a stray notion.

Toot - toot..

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RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 01-30-2024

Of attributable Bollocks and:-

Squibs purporting to be 'Bombshells'.

I have cribbed the quoted 'text' from a News.com article, by Liam Beatty. We can readily forgive the journalistic naivete as the thick coat of gloss and ATSB mumbo jumbo would mislead many of those who have a nodding acquaintance with air operations - even at the professional level. There, compliance is paramount with 'grey-ish' letter law; the first question asked of any operation "is it legal"?  Is it "safe"? (whatever that may mean) is rarely asked of a 'routine' matter. The precursor is a notion that if it is 'legal' then, it must be 'safe'; or, at least able to be 'seen' to be during the 'investigation' then all is well. Enter ATSB Bollocks #1.

ATSB Bollocks #2 - "An investigation into a horror helicopter crash which killed five people in Victoria has concluded the flight should have been cancelled because of weather conditions."

Well; this was a 'commercial' operation, the paying passengers would have an expectation, even if pre warned, to get where they want to go. Unless the 'operations' staff (meet and great) can declare, categorically, that the weather conditions totally preclude departure - even then eyebrows will be raised. Out will come the I-phones calls will be made and weather conditions checked. Best result, seasoned travellers will wait' or reschedule, they understand; the not so much crew will haul off in a huff, find another operator and have a 50/50 chance of securing a ride. Such is human nature. However, as most 'commercial' VFR operations will do; they will launch and compare the 'actual' conditions to the 'forecast' conditions; maybe they squeak through; maybe they don't; such is the game of VFR operations, and much depends on many complex factors. But, on the day's forecast, provided the passengers were happy to accept that the weather was forecast as 'sketchy' and the possibility of a return to base was on the cards; then it would be acceptable to go and see what conditions really were. That 'risk' element quite operationally sensible and commercially acceptable.

ATSB Bollocks #3 - "A new report by the Australian Transport Safety Bureau released this week found Mr Neal and the second pilot were not qualified to fly in rough weather and held concerns about the conditions before the trip."

Tricky one this; not  concerned enough to exercise 'command prerogative though. 'Inadvertent' or 'deliberate' entry into cloud? That is the question. Clouds ain't invisible; nor is good old terra firma; particularly of the mountainous kind. Take a look through the cockpit window; is there a gap between cloud and the bricks or is there not? No, then can we step around it? It is a yes or no question. Are you above the lowest safe height for operating in cloud? It is a yes or no question. If one cannot 'see' a clearly defined 'road ahead' then one is obliged to turn away into 'suitable' conditions; or 'better' than that ahead. It is 'unwise' to persist into cloud without a safe height and/or wriggle room, thereby intentionally closing the only exit available - that being the one you just left behind.

ATSB Bollocks #4 - "The first helicopter broadcast to Mr Neal he planned to perform a U-turn, with Mr Neal descending and hovering as the first pilot turned back."

Consider this situation; carefully, from the beginning, start at the very basic level. Begin with the CASA accepted 'operations manual' find the section which defines company policy and the 'does, don'ts of operational procedures/practice. Now then, turn to the page which outlines 'tandem' or 'formation' or 'following' where two aircraft are dispatched to the same destination; in sketchy weather conditions under the Visual Flight Rules. Can you find a clearly enunciated section defining the procedure for when the 'lead' aircraft has 'inadvertently' entered cloud and is reversing track? No? Think on it. The 'following aircraft is in close proximity to the same 'weather'; can't descend too much due to 'the bricks'; can't climb lest the aircraft 'inadvertently' enters 'cloud' - so that aircraft is 'boxed-in' on track trying to peer into cloud to see the opposite direction aircraft emerging from that same area. Russian roulette? anybody? OK, so now try to find the section which outlines a 'sensible' approach to this scenario. What about say a 12 minute delay between the two aircraft? Say based on 80 knots; that provides a 16 mile separation and, the all important 'time' element for the lead aircraft to safely leave the cloud which had been 'inadvertently' entered, with the following having time, space and visibility to avoid the 'opposition'. There are several different ways to avoid increasing the risk to an unacceptable level; whichever 'system' is used can be tailor made to suit the proposed operation. This accident is the second of it's kind now. Have the ATSB or CASA come up with suggestions, solutions or even some sage operational advice?

ATSB Bollocks #5. "Records retrieved from Mr Neal’s craft indicated he then attempted to perform a “steep turn” to exit the cloud quicker, but instead plunged to the ground and struck an old growth tree before bursting into flames."

The high body count, world wide due to similar situations is worthy of note; it is one of the longest standing 'events' and continues 'unabated'. Research shows a couple of clearly defined 'patterns' of experience level and of early 'training'. Many of these pilot's encounter with 'real' weather' is their very first; often actions are based on previous encounters with a lighter weight (for wont of better) of weather; got away with it before - so, push on and chance my (dumb) luck. Many start and finish their training in 'good' conditions; sat in the crew room during the 'bad'. Weather flying 'experience' reduced to reading and listening. Only my opinion, but I believe that aspirant pilots need to 'educated' from the 'get-go' in weather appreciation and operation. (End of Hobby horse ride)...

ATSB Bollocks #6. "A new report by the Australian Transport Safety Bureau released this week found Mr Neal and the second pilot were not qualified to fly in rough weather and held concerns about the conditions before the trip."

What a pointless, artificial cop out. There was no surprise 'found' about the qualifications - it was clearly printed on their bloody licence. VFR - Visual Flight Rules. The requirements for 'legal' operation clearly, with criminal penalty attached, are spelled out in the regulations. I sincerely doubt there is a pilot in the world who has not 'pushed' the specified limits or at least given them a gentle nudge; however. As DRS Bader said;

“Rules are for the obedience of fools and the guidance of wise men.”

There are times when a gentle 'bending' of a rule may be forgiven; but the thoughtless persistence to continue on, until immersed in cloud, without instrument training or 'auto' something (enter temptation sans 'clear thought' for the way ahead) is piss-potical, in the extreme. Nuff said methinks.

ATSB Bollocks #7. “The significant deviation of the pitch attitude during the turn was likely unintentional and the result of inadequate pilot control due to a lack of instrument flying training and artificial stabilisation,” the report found.

Words fail here; its just twaddle, chicken feed for the media vultures. ATSB is devolving into a top cover PR machine; lots of 'stuff and nonsense' but very skinny (anorexic) when it comes to solutions or resolution, let alone aiding and abetting prevention of repeat performances. Why does ATSB even exist? Gods know CASA have enough 'top cover' and the media will write and promote anything which titillates and sells advertisement.

That is it: rant over. My apologies to my peers and betters who actually know and understand the state of play; but to my simpleton's mind it is clear that this farcical, disingenuous, dangerous approach to and lip service paid to 'real' safety outcomes needs some 'delicate' adjustment of the scales; with big hammer. Standing by for incoming.

Toot - toot.....

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