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

+- AuntyPru Forum (https://auntypru.com/forum)
+-- Forum: MH 370 -Media unscrambled. (https://auntypru.com/forum/forumdisplay.php?fid=53)
+--- Forum: Accidents and aftermath (https://auntypru.com/forum/forumdisplay.php?fid=60)
+--- Thread: Closing the safety loop - Coroners, ATSB & CASA (/showthread.php?tid=97)

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-18-2024

Mangalore inquest and Vic Coroner Aviation inquests? - 

Via this week's SBG and the UP:  "..Accident investigation descended into little more than a PR exercise, all to promote Popinjay from his level of incompetence to new heights.."

Quote:ER_BN

Advance,

Thank you! If you posted a link (underlined), I could not access it. May be my ongoing and increasing dementia.

However the coroner’s office has been very helpful and I believe there is a weblink available for people not able to attend in person. One can watch it just like Senate Estimates, not that I’ll be using it and it does raise some issues…

I’ve been assured the inquest is open to the general public, not that I have a “seat” at the table, it will be a case of quiet observation whilst there and reflection after each day.

Just like Global Warming, I am not optimistic about this inquest but I still have hope, if only for the relatives of the four pilots and also for the air traffic controller. My analysis would indicate those desires are not mutually exclusive…

I expect that hope to be extinguished after the inquest. I expect it to be another VH-TNP / Benalla.

The ATSB report in my opinion is full of omissions and misinformation. I am not suggesting a conspiracy, merely (like a lot of things in Australia) severely flawed by a combination of seeming incompetence, mediocrity and self interest. I cannot see any other reason for the strange content and simplistic conclusions.

The only good news is that the inquest has been given the varsity i.e. Justice John Cain, the Chief Coroner of Victoria.

However, if the right witnesses aren’t called and the right questions aren’t asked coupled with accurate physical evidence; it doesn’t matter how good the intentions are “…the road to hell is paved….” etc.

As far as I’m concerned were FS still in place the accident would not have happened. That in itself is a sad indictment of the “advancement” of policy in regard to aviation safety specifically to airspace in Australia below 10,000 ft since the early 1990s. Technology and surveillance are not always “an advancement” especially in the transition from humans to automation.

I am not sure having a front row seat was a good idea and was in fact really just a “poisoned” chalice.

Sigh!

With a quick search across the Vic Coroner website, I was able to find the following for next week's scheduled inquest hearings: https://coronerscourt.vic.gov.au/inquests-findings/court-hearings

Quote:Name Mangalore Aircraft Accident

10:00am
Location Southbank Court 1
65 Kavanagh Street, Southbank VIC 3006
Ph : 1300 309 519
Fax : 1300 546 989
Court reference number COR 2020 0950, COR 2020 0971, COR 2020 0951 & COR 2020 0976
Coroner State Coroner Judge John Cain
Case Type Inquest

(Listed for Monday 25th through to Thursday 28th)

While trolling the Vic Coroner website, I came across the Coroner's inquest findings for other Aviation accidents, including one, that took me completely by surprise, listed as the 'Essendon Plane Accident'??

Ref: https://coronerscourt.vic.gov.au/sites/default/files/Coroner%27s%20Findings_Essendon%20Plane%20Accident.pdf

This report was apparently delivered on the 30 September 2022. Whether or not it was publicly available from that date - who knows? I certainly can't recall there being any MSM press coverage in regards the findings?

One thing that is obvious from reading the report, is that the splintering off of the bollocks Essendon DFO Approval Process investigation, with the final report being published 30 June 2023, was a Hood masterstroke as there was not one reference to the DFO building as being a factor causal to the accident. JOB DONE - the PILOT DONE IT! 

For further proof of the pilot being completely stitched up, with CASA being a perfect model litigant and a responsible (but not liable) Federal government safety regulator see - HERE - for the legal WWC (Weasel worded confection) in reply to the CASA addressed Coroner recommendations..    

There is also an interesting (same theme -   ) CASA LSD reply for the recommendations that came from the 'Barwon Heads Accident': https://coronerscourt.vic.gov.au/sites/default/files/2021-09/Barwon%20Heads%20Accident%20response%20to%20recommendations%20from%20CASA_CHAMBERLAIN%2C%20BRADLEY%2C%20HATELEY%2C%20FLINN_1.pdf

Quote:Dear Registrar,

Investigation into the deaths of Donald Hateley, Ian Chamberlain, Dianne Bradley and
Daniel Flinn - Barwon Heads Aircraft Crash

We refer to Coroner Jamieson’s findings dated 11 February 2020 and the two
recommendations directed to the attention of the Civil Aviation Safety Authority (CASA).

At the outset, CASA sincerely apologises for the delay in responding to the recommendations
which occurred due to an administrative oversight.

In respect of the two recommendations, the following responses are provided:

Recommendation 1 – that CASA mandate the use of SARTIME for all Visual Flight Rules
flights over water

1. Upon reviewing the Coroner’s findings, we note that CASA already has requirements
in place for the nomination of a search and rescue time (SARTIME) for visual flight
rules (VFR) flights over water.

2. As noted in the findings (see [123] – [126] of the Background Circumstances and [7]
of the Comments), pilots conducting VFR flights over water are already required to
submit a SARTIME flight notification to Airservices Australia or leave a flight note with
a responsible person. This is by force of regulations 240 and 241 of the Civil Aviation
Regulations 1988 (CAR) and paragraph 1.10 of the Aeronautical Information
Publication (AIP) En Route Supplement Australia.

3. If the focus and intent of the recommendation is that CASA require the use of
SARTIME only and not allow the leaving of a flight note for VFR flights over water,
then CASA confirms that the recommendation will be taken into consideration as part
of the ongoing regulatory development activities referred to further below.

4. Of particular relevance to this recommendation is that, following extensive
development and community consultation over a number of years, new regulations
contained in Part 91 of the Civil Aviation Safety Regulations 1998 (CASR) for the
conduct of flight operations will come into force on 2 December 2021. These
regulations will cover VFR flights over water and flight monitoring rules including
SARTIME requirements. In particular, Division 91.D.3 provides for flight notifications
as follows: (read for the CASR references etc)

Recommendation 2 – that CASA increase IFR training and recency requirements for
PPL candidates and holders, for the purpose of, but not necessarily limited to, further
education for candidates on the fatal dangers of inadvertent entry into IMC

8. At the outset, we draw to attention concerns as to references to instrument flight rules
(IFR) training in relation to private pilot licence (PPL) holders. IFR training is not
mandatory for PPL holders and references of this kind have the potential to confuse.

9. Candidates for and holders of PPLs who operate in Visual Meteorological Conditions
(VMC), being the majority of PPL holders, are not required to complete IFR training
and there is no recency requirement. However, these pilots are required to
demonstrate basic instrument flying competency as a candidate for and ongoing
holder of that licence. The assessable standards are consistent with the international
licensing standards and have been in place for many years.

10. CASA is generally satisfied that the aeronautical knowledge standards and the basic
training for instrument flying, as opposed to specific training for IFR operations, are
currently appropriate. Assessment of basic instrument flying competency is also
included as part of the mandatory biennial flight review standards for PPL holders.

11. Candidates for a PPL are also taught of the serious risks of inadvertent entry into
instrument meteorological conditions (IMC) as part of the aeronautical knowledge
standards and practical flight competencies which they must be able to demonstrate
(including via theoretical and practical examination) prior to the issue of a PPL. These
standards and competencies are set out in the Manual of Standards issued to support
Part 61 of the CASR.

12. In addition, CASA provides many safety education products including seminars and
materials such as the magazine, Flight Safety Australia, which regularly deal with the
topic of inadvertent entry into IMC. For example, a recent article in Flight Safety
Australia titled “Weather to fly” dealt with these issues. This article can be accessed at
Weather to fly . Examples of the kinds of relevant material routinely addressed at
aviation safety seminars can be accessed as “Enhancing pilot skills – expect the
unexpected“.

13. To the extent that the recommendation is targeted at CASA increasing IFR training
and recency requirements, CASA notes that IFR training, by its nature, is designed to
teach the skills necessary for pilots to safely fly by reference to instruments only. It
does not form part of the general PPL syllabus of training as it is an additional skill
and separate rating for flying operations conducted under the IFR. CASA considers
that the training presently provided to PPL pilots around the need to ensure they stay
in VFR conditions is adequate and that more specific IFR training is only necessary
for pilots who wish to operate under the IFR.

14. CASA considers that training for inadvertent entry into IMC is more appropriate for
pilots rated only for VFR conditions. Without appropriate prior training and an aircraft
designed for IFR operations, such pilots are more likely to become spatially
disoriented or unable to safely operate the aircraft in IMC.

15. Therefore, while it does not propose to take any action in relation to this
recommendation at this stage, CASA is proposing a review of the competency
standards and the two-yearly review of proficiency rules (known as a flight review) for
private pilots in the next 18 months. A review of the basic instrument flying standards
and the related non-technical skills and human factors required of PPL holders will be
included in that review.

Please contact the writer should you require further information or should you have any
further enquiries concerning this matter.

Yours sincerely,


Anthony Carter
Special Counsel
Litigation, Investigations
and Enforcement Branch

Ph: (02) 6217 1151
Fax: (02) 6217 1607

Email: anthony.carter@casa.gov.au

Also of interest from the Coroner Findings for Aviation was a response from the Department of Infrastructure, Regional Development and Cities and the Australian Transport Safety Bureau in reply to recommendations issued to the ATSB in the context of a 13 March 2016 double fatal microlight trike accident at Yarrawonga (Note the signatories -  )





(For the combined Vic Coroner Aviation accident reviews and inquest findings listed see - HERE)

MTF...P2 

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 03-28-2024

Mangalore midair Coroner inquest update?? - 

Via the SMH:

Quote:Inquest probes why no safety alert was sent to pilots before planes collided

Erin Pearson
March 25, 2024 — 5.50pm

In the two minutes before two small aircraft collided midair in the first crash of its kind in Victoria, an air traffic controller monitoring the airspace received two alerts about their trajectories.

Each time, he silenced the alert.


The aftermath of the fatal collision between two planes in Mangalore in February 2020.

At the time, proximity alerts – activated when planes are forecast to come within a certain distance of each other – were a frequent occurrence in the busy non-controlled airspace near Mangalore Airport in central Victoria.

Air traffic controller John Tucker said the alerts were so common that he believed more than half were false or nuisance alerts, and that it was common practice for staff to silence the sounds.

But less than a minute after he silenced the second alert, two training flights collided eight kilometres south of Mangalore Airport.

Pilots Ido Segev, 30, Peter Phillips, 47, Christiaan Gobel, 79, and Pasinee Meeseang, 27, were killed in the collision at 11.24am on February 19, 2020.

It was the first midair collision between civil aircraft operating under the instrument flight rules and procedures – where pilots cannot rely on visual cues – in a non-controlled airspace, according to the Australian Transport Safety Bureau.

On Monday, Tucker, employed by Air Services Australia, told the first day of the inquest into the deaths that he believed warning alerts he was getting about the two aircraft in the minutes before they crashed were nuisance alerts that didn’t require a response.

He told the Coroners Court he had alerted each aircraft about the other after Meeseang signalled that she and Gobel were about to take off from Mangalore Airport as Segev and Phillips approached.

Tucker said the rules stated it was up to the two planes to communicate with each other to maintain a safe passover.



But the inquest heard both planes continued on their trajectories: Gobel and Meeseang ascended as Segev and Phillips descended.

The pilots’ final radio transmissions were played to the inquest as family members sat in court.

Tucker, an experienced air traffic controller who oversaw the airspace above Mangalore on the day, said by the time the final warning siren rang out in his office, it was too late to issue a safety alert as he believed it would only distract the pilots.

In his statement, he said he believed both aircraft had levelled off about 1000 feet (about 300 metres) apart and there was no risk of collision.

Soon after, Tucker said he noticed both aircraft had disappeared off his screen, and when he tried to contact them, there was no response.

On Monday, he acknowledged a post-incident report which suggested both aircraft were continuously climbing and descending in the minutes before the fatal crash.

“I made a judgment call which was not to issue a safety alert. At the same time I had to deal with other traffic at Wangaratta,” Tucker said.

“I expected the pair to be talking to each other.”


Air traffic controller John Tucker (right) outside the Coroners Court on Monday.CREDIT:CHRIS HOPKINS.

The coroner is investigating what led to the midair collision, who had what responsibilities on the day and whether collision warning technology should be mandated, among other things.

Outside the court, Segev’s fiancee, Brianna Sutcliffe, said the pair planned to marry in 2020 and have a family together. She vowed to fight for transparency about what happened given little is known about why the crash occurred.

“The extent of pain and suffering this has caused myself and Ido’s family is insurmountable and enduring. Not a moment goes by where I am not consumed by the traumatic events that surround his passing,” Sutcliffe said.


Brianna Sutcliffe, the fiancee of pilot Ido Segev.CREDIT:CHRIS HOPKINS

“Ido would have done anything for me, and now it is my turn to repay the favour. I will not rest until I receive transparency regarding the events surrounding the loss of my soulmate, Ido.”

Court documents released to the media show Meeseang was a Thai national who was in Australia to train as a commercial airline pilot. She was due to complete her instrument rating training on the day of the collision.

Phillips was the chief pilot at the Peninsula Aero Club.

The inquest continues.

MTF...P2 

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Kharon - 03-29-2024

Coroners Court Vic. Barwon Heads -

Poor old Coroner; what a tangle. Recommendation #2 caught my attention.

Recommendation 2 – that CASA increase IFR training and recency requirements for PPL candidates and holders, for the purpose of, but not necessarily limited to, further education for candidates on the fatal dangers of inadvertent entry into IMC.

Aye, but: is that a 'real' solution?  The CASA response below defines the perennial problem, one which has never, globally, ever really been 'solved';. 

13. To the extent that the recommendation is targeted at CASA increasing IFR training and recency requirements, CASA notes that IFR training, by its nature, is designed to teach the skills necessary for pilots to safely fly by reference to instruments only. It does not form part of the general PPL syllabus of training as it is an additional skill and separate rating for flying operations conducted under the IFR.:-*CASA considers that the training presently provided to PPL pilots around the need to ensure they stay in VFR conditions is adequate and that more specific IFR training is only necessary for pilots who wish to operate under the IFR.*

That last sentence presents a clear, cut and dried stand point, which, in essence, is bang on the money; no argument. However; VFR pilots pushing on into Instrument conditions continues, world wide, to be a big number on the butchers bill. A solution is required and IMO it is not CASA's, FAA, CAA or any other 'authorities' job to stop the body count. Perspective is needed from the pilot body; that (IMO) is where the solution lays.

Both question and problem for the VFR pilot lays within the ever asked question -  'go' or; not go? - that is the question; ain't it?

“Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,etc...

Several ways to go toward a 'solution' which does not involve 'complex' regulation or outrageous costs. But 'brass tacks' first: if you were scheduled for heart surgery and your plumber turned up to do the job; or, if a power line fell across the garage roof, would you get a ladder from the shed, climb up and repair the break? What if there was a gas leak at home; would you try to fix it with a blow torch? Of course not; like fire fighting or Air Traffic control at Mascot - these are tasks which require dedicated training and a proven skill set. So why would anyone persist in flying into weather condition for which they neither have the training, demonstrated skills and experience to do the bloody job. Its balmy, statistically proven to be so and dangerous. 'Managing a flight, in real IFR weather is governed by some rules which are an unbreakable tenet  for survival; Lowest safe altitude; minima; ice management; fuel management; diversion; and the ability to draw the line; thus far and no further will I go.

The basic ability to execute a Rate 1 turn; on the clocks should be and was taught from the very first flying lesson; (well back in my day it was). Turn crosswind - set the turn angle by visual reference; then confirm - 80 IAS = 8+7 :: a Rate 1@15° angle of bank, ball in the middle - good job ; habit formed from first circuit. Basic escape from the insidious Bollocks of 'inadvertent'. There is NO inadvertent involved - none whatsoever.

One could lay some 'blame' at the feet of the BoM; they have a wide margin for error on a forecast. This works both ways; - for and against an outcome. It is quite possible to have to battle your way down to 'minima' and just 'squeak' in - legal on a reasonable forecast; and be equally worried along the journey about a forecast only to find an easy approach in the mildest of conditions. Such is the inexact science of computer generated models. BUT, that is what you have to work with. So then; what must we teach our VFR pilots?

Only my considered opinion and an insignificant one at best but; try I must.

Item 1 : ensure, from the beginning of 'training' that all in flight manoeuvres are initially set up by visual reference and confirmed by flight instruments; make it a life long habit, deeply entrenched.

Item 2 : Encourage 'students' to not just 'pass' the Met exam. Hell's bells' the BoM are only making educated 'guesses' and working with 'trend' models to forecast the weather and they all hold university degrees in the subject (well, mostly). Pilots (no matter the stamp) must; and I do stress 'must' be able to evaluate a 'forecast' and formulate a plan of action based on the worst case; particularly with regard to icing, turbulence and the effects of both wind and temperature on the terrain and flight path. Rule 1 - always - always - always have the 'back door' wide open. If trumps turn to crap - then at least; at the critical juncture; there is a viable, pre formulated 'escape' route (plan of action - just in case) available from the 'sticking points' noted along the flight path.

Item 3 : While I am a great believer in and frequent 'user' of Auto pilot and GPS systems; I am not certain that an 'early' dependency on such luxury items is a good thing in the early stages of training. Only my opinion; but there is a 'professional' need to be grounded in the real deal; hand flying in the bumps, awareness of the terrain, and understanding of where the weather is, where its likely to be better and where the 'trap' points are is an essential element. My grand kids can type 60 WPM - left handed on a 'screen' - but the notion of descending, over rising terrain, in cloud which is orthographically uplifting, while flying an aircraft is beyond their comprehension or learning.

For a complete diorama of the current shortcomings in pilot basic training - look no further than the BN2 event in Tasmania. No ones fault - but it does beg questions a Coroner has no chance of answering.

Here endeth the ramble, with apologies to the pureist and academics and law makers; but IMO the 'problem' begins (and ends) at grass root level; barring that there will always be 'them as what's gunna do-it' anyway. Those we cannot help.

Toot toot.

---

RE: Closing the safety loop - Coroners, ATSB & CASA - Peetwo - 10-31-2024

Red Rat the answer to all things on Oz Aviation Safety?? -   

Via the Oz:

Quote:Qantas to open new ‘safety academy’ in 2025 to teach other industries how to avoid disaster

Qantas is preparing to cash in on its solid safety record by lending its name to a new “safety academy” to be run in partnership with Griffith University and RMIT.

People seeking to enhance their safety credentials across a wide range of areas, including health, cyber, data and risk management will be able to pay to undertake a short course at the virtual academy from next year.

Qantas executive manager of group safety and health Ian Hosegood said the airline’s reputation as a safety leader was well known and the team looked forward to sharing that expertise in an increasingly safety-conscious world.

“I think it’s becoming more and more important that we maintain and develop the skills of safety professionals because there’s been an exponential change in some of the complexity,” Dr Hosegood said.

“With technological advances, with changes in regulation, and disruption into different industries, I think the pace of change is now much greater.”

He said Qantas personnel would be involved directly in the academy by providing mentorship and teaching, and developing materials with Griffith and RMIT.

“As we move into the later phases, we could have work placements in Qantas so people outside of Qantas would be able to come and have some integrated work learning within the Qantas environment,” Dr Hosegood said.

The establishment of the academy, which would offer online webinars in the first instance, would be funded by Qantas, Griffith and RMIT.

Courses – or micro credentials – would be paid for in much the same way as other university courses, with the cost expected to be within $500–$3500.

Credits from the courses would count towards other relevant postgraduate qualifications.

“This is not a cookie-cutter approach to safety science, but micro credentials with depth which offers a postgraduate learning environment for professionals who want to advance their careers and take the next step,” said Griffith Sciences Group dean Rosalind Archer.

RMIT Aviation Academy director Lea Vesic said the academy would help build a pipeline of safety leaders with a broad set of critical skills.

“RMIT’s partnership with Qantas is testament to the quality of our training and leadership – not just in producing job-ready graduates but fostering collaboration across the sector,” Ms Vesic said.

“These types of industry partnerships – and innovative training delivery – will be even more critical as we look to futureproof the aviation industry in Australia.”

Qantas also announced plans to invest $40m in a new ground training facility at its Mascot campus in Sydney, to keep its own people skilled in emergency procedures.

More than 5000 pilots and cabin crew were expected to be trained at the facility each year, once it opened in mid-2026.

Qantas chief executive Vanessa Hudson said that with more than 100 new aircraft on order for the airline and low-cost carrier Jetstar, the investment in training was vital.

“Each of those new aircraft represents a growth opportunity for our people and the broader industry,” Ms Hudson said.

“Our multimillion-dollar training investment means there will be new facilities and state-of-the-art equipment across Australia to train our current pilots and cabin crew, as well as the thousands of crew expected to join the Qantas Group over the next decade.”

Qantas already lends its name to a pilot training academy in Toowoomba and will open an engineering academy in Melbourne next year.

And courtesy of Lea Vesic, via LinkedIn...  

Quote:Lea Vesic 
The sky is not the limit, it is just the view. Executive MBA Candidate

1w • Edited •  1 week ago

Follow

? Exciting Announcement! ?
I am thrilled to announce the establishment of a new Safety Academy, a strategic partnership between Qantas, Griffith University, and our aviation team at RMIT Aviation Academy. This collaboration is a significant step forward in building a safer, more resilient future for aviation.

Backed by Qantas' recent $40 million investment in aviation training and skills development, this Academy will focus on delivering cutting-edge safety training to the next generation of aviation professionals. By leveraging the expertise of Qantas' world-class safety practices and the University's academic leadership, we aim to set new benchmarks in safety standards for the aviation industry.

? This initiative is designed to:

- Equip students and professionals with advanced safety competencies
- Foster a culture of safety excellence across the aviation ecosystem
- Meet the evolving demands of the industry as we look to the future

I'm incredibly proud to be a part of this transformative journey, and I look forward to seeing the positive impact this Academy will have on aviation safety worldwide.

Ref: https://www.qantasnewsroom.com.au/media-releases/qantas-to-invest-more-than-40-million-in-the-future-of-aviation-with-new-skills-and-training-initiatives/

Hmm...Lea Vesic why does that name ring a bell...

Quote:
Aviation & Maritime Advisor 

Office of the Deputy Prime Minister of Australia - The Hon. Michael McCormack MP

Mar 2020 - Jul 2021 · 1 yr 5 mos

Canberra, Australian Capital Territory, Australia

MTF...P2 

---