The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Peetwo - 09-09-2016

Spot the trend -

Off the latest bollocks ATSB SIB, Planetalking picked up on incident AO-2016-015:

Quote:How a glider and a regional turbo-prop nearly hit over Orange
Ben SandilandsSep 8, 20162 Comments
Gliders and airliners keep just missing each other at country airports and the ATSB spells out the risks in this close call earlier in the year

 
But then I referred to the rest of the SIB and I realised that all 10 of the desktop investigated
incidents/accidents were all near collisions:

Quote:Aviation Short Investigations Bulletin - Issue 51

Summary

The Aviation Short Investigation Bulletin covers a range of the ATSB’s short investigations and highlights valuable safety lessons for pilots, operators and safety managers.

Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research.

Issue 51 of the Bulletin features ten safety investigations:

• Near collision involving SAAB 340, VH-ZLA, and Glaser-Dirks DG-800B glider, VH-IGC
  
• Near collision between Schempp-Hirth Janus glider, VH-GWQ, and Rolladen-Schneider LS3-A glider, VH‑CQP 
  
• Near collision involving Glaser-Dirks DG-1000 glider, VH-NDQ, and Jabiru J170, 24-7750
  
• Near collision involving Pacific Aerospace CT4, VH-YCO, and Piper PA-28, VH-WJZ
  
• Near collision involving Piper PA-28, VH-BYE, and Cessna 152, VH-CRP
  
• Near collision involving Morgan Cheetah, 19-5456, and Grob G115, VH-ZTA
  
• Near collision involving Robinson R22, VH-MFH, and Lancair, VH-XCG
  
• Near collision involving Cessna 177, VH-OOJ, and Cessna 172, VH-VSO
  
• Near collision involving Robinson R22, VH‑JKH, and Cessna 182, VH‑YKM
  
• Near collision involving Piper PA-32, VH-NKA, and Cessna 210, VH-SQT
  

 
Type: Aviation Short Investigation Bulletin

Investigation number: AB-2016-085
Series number: 51
Publication date: 8 September 2016
 



Last update 08 September 2016 

 
Hmm....so anyone spot a trend here?

MTF...P2

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RE: The search for investigative probity. - Gobbledock - 09-09-2016

P2;

Hmm....so anyone spot a trend here?

Yes. None of the gliders have ADS-B, yet!!!

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RE: The search for investigative probity. - ventus45 - 09-11-2016

As a (former) glider pilot, I have been, and still am, forcing myself, to not comment.

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RE: The search for investigative probity. - Peetwo - 09-17-2016

Sully and the search for IP -

(09-12-2016, 08:13 PM)Peetwo Wrote:  While on Sully -

It always amazes me the strange parallels that play out on opposite sides of the globe in the world of aviation accident investigation...

The following New York Times article by Christine Negroni highlights the NTSB sensitivity as being portrayed as 'sullying Sully', in his command actions in the 208 seconds it took to successfully dead stick an A320 into the Hudson River, with a zero fatality outcome:

Quote:‘Sully’ Is Latest Historical Film to Prompt Off-Screen Drama
By CHRISTINE NEGRONI
SEPT. 9, 2016


 
Tom Hanks as Capt. Chesley B. Sullenberger III in “Sully.” Credit Keith Bernstein/Warner Bros. Pictures, via Associated Press

Compare that to these comments from the original ATSB Investigator in Charge of the VH-NGA (Norfolk Is - PelAir) ditching investigation: 

  
And as they say - "the rest was history..."

Next on Sully was this excellent perspective from A320 driver Owen Zupp , via Oz Aviation...

The parallels with ATSB historical and ongoing botched investigations like the PelAir debacle or the MH370 saga continue. Therefore I thought it prudent to carry the modern day Annex 13 AAI lessons learnt from the original NTSB investigation and 'Sully' the movie across to the continuing search for ATSB investigative probity...

To begin here is (IMO) a particularly relevant quote from today's Byron Bailey slap at the ATSB, via the Weekend Oz.. :

Quote:The US National Transportation Safety Board, the world’s premier aviation accident investigation board — using the opinion of bureaucrats relying on armchair aviation specialists, computer simulations and simulators — subjected the captain’s decision to ditch in the Hudson River to close scrutiny.


They did contend that the aircraft was capable of returning to LaGuardia or reaching the nearby Teterboro airport in New Jersey (an airfield I have flown out of recently).
When presented with the opinion of the flight crew and technical information from the black boxes, the NTSB was gracious enough to concede its initial premise was flawed.
How unlike the Australian Transport Safety Bureau’s handling of the missing Malaysia Airlines flight MH370. P2 - In bold swap for your favourite ATSB cocked-up/cover-up investigation

 Next, in a further strange irony - , the following OP from the excellent (white hat fraternity) CASA publication Flight Safety:

Quote:Silver screen, silver tongues
Sep 16, 2016

Cinematic mythmaking is not funny when it detracts from safety

Aviation and the movies were two transformative technologies of the 20th century. Yet they have long had an awkward, unproductive relationship. The evidence for this is that there are few, if any, masterful films about flying, and many risible ones.

A list of the greats might include The Right Stuff (1983), but even here the imperatives of keeping the script snappy slice out much of the attention to detail safe flight depends on. Test pilots do not attempt altitude records on a whim, for example. (Surviving ones don’t, at any rate.)

The list of stinkers is long, and, to be fair, amusing, particularly if your idea of amusement is bitter laughter and having your ideas about the stupidity of the mob confirmed. They include the Airport series of 1970s disaster films, The High and the Mighty (1954), an unintentionally hilarious study of pre-CRM flight decks, complete with face-slapping; Flightplan (2005), which attracted the ire of the Association of Professional Flight Attendants; and the high point of the genre, Snakes on a Plane (2006).

‘So what?’ you might say. Pilots, engineers, controllers, cabin crew and managers go to the pictures for the same reason as everyone else; to be entertained, not to see their profession mirrored in excruciating detail. The problem is myth. Hollywood deals in myth, but aviation can’t afford to because myths get in the way of safety. The myth of the all-knowing, steely-eyed, square-jawed aviator is undoubtedly appealing, but was arguably also the source of so many avoidable accidents that aviation developed crew resource management in response, to puncture it.

Sully, the dramatisation of US Airways flight 1549, currently screening in Australia, is a textbook example of this hazard. And in aviation safety management terms it does create a hazard. When real life events become scripts it’s inevitable, and mostly harmless, that composite characters are created, timelines telescoped and side issues removed. If not the story would be too unwieldy. But Sully commits a graver sin. By presenting the US National Transportation Safety Board as small-minded bureaucrats, it delegitimises their work. This is serious because the NTSB has no power to enforce its findings, relying instead on its reputation as an independent inquirer. Any damage to that reputation is a blow against safety. By portraying investigators as bloody-minded buffoons—when the public record of the investigation shows nothing of the sort—the movie is also a swipe at the concept of safety reporting and just culture.

While most readers of this story would understand the distinction between reality and fiction, many non-flying audience members won’t, in the same way laypeople watching Flight (2012) might walk away thinking that secret and obsessive drinking is the mark of a master pilot, and that you speed up to penetrate a storm cell. In the slickly filmed and from a cinematic point-of-view, highly competent Flight, these howlers were perhaps forgivable. They are less so in a script that takes aim at one of the fundamentals of aviation safety.

FSA team
RELATED ARTICLESMORE FROM AUTHOR

Investigators say ‘Sully’ movie gets it wrong

Then from the New York Times a rather scathing look at the tardiness of the FAA to respond to SRs generated from the NTSB 'Miracle on the Hudson' investigation:

Quote:'Miracle on the Hudson' Safety Advice Not Carried Out

By THE ASSOCIATED PRESS SEPT. 15, 2016, 10:43 A.M. E.D.T.
WASHINGTON — In the seven years since an airline captain saved 155 lives by ditching his crippled airliner in the Hudson River, there's been enough time to write a book and make a movie, but apparently not enough to carry out most of the safety recommendations stemming from the accident.

Of the 35 recommendations made by the National Transportation Safety Board in response to the incident involving US Airways Flight 1549, only six have been heeded, according to an Associated Press review of board records.

The movie "Sully," which opened in theaters last week is based in part on an autobiography by veteran pilot Chesley "Sully" Sullenberger, played by Tom Hanks. It celebrates how Sullenberger, along with his co-pilot, flight attendants, air traffic controllers, ferry boat operators and first responders, did their jobs with professionalism and competence, averting a potential tragedy. The plane lost thrust in both engines after colliding with a flock of Canada geese shortly after takeoff from LaGuardia Airport in New York. No one died, and only five people were seriously injured.

"The FAA was very upset back then that we made any recommendations at all," recalled Tom Haueter, who was the NTSB's head of aviation safety at the time. "They thought this was a success story."

But to investigators, the event turned up problems. "This could happen again and we want to make sure that if it does, there are some better safety measures in place," Haueter said.

Fourteen of the recommendations issued to the Federal Aviation Administration and its European counterpart, EASA, are marked by the NTSB as "closed-unacceptable," which means that regulators rejected the advice. One has been withdrawn, and the rest remain unresolved.

The untold story of the "Miracle on the Hudson" was the part luck played in preventing catastrophe on that freezing afternoon in January 2009. The wind chill was 2 degrees and the water temperature was 41 degrees, raising the risk of "cold shock," a condition in which people lose the use of their arms and legs, usually drowning within 5 minutes.

It was sheer chance that the plane, an Airbus A320, was equipped with rafts, life vests and seat cushions that can be used for flotation. The equipment is only required on "extended overwater" flights, and not on Flight 1549's New York to Charlotte, North Carolina, route.

The NTSB recommended requiring life vests and flotation cushions on all planes, regardless of the route. But the FAA responded that it was leaving that up to the airlines.

The board also recommended that vest storage be redesigned for easier retrieval. The NTSB's investigation found that only 10 passengers retrieved life vests and not all of them put them on correctly. Despite some changes by the FAA, the board says it still takes more than a few seconds to retrieve vests, which is as much time as passengers are willing to take when exiting a plane filling with water.

Because Flight 1549's descent was faster than the plane is designed to handle for a ditching, the underside of the aircraft was damaged when it hit the water. The two rear rafts were submerged and unusable. That left only the two forward rafts, which are designed to hold a maximum of 110 people — well short of the 155 on board. Many of the passengers wound up standing on the wings as the plane gradually sank into the river.

The NTSB recommended changing the location of the rafts to ensure capacity for all passengers, since it's unlikely the rear rafts would be available. The FAA rejected that, saying that if Sullenberger had followed Airbus' directions on descent speeds for ditching, the rear rafts would have been usable. The NTSB said the ability of pilots to achieve those descent speeds has never been tested and can't be relied on.

Some passengers wound up using the inflated exit ramps as rafts even though they're not designed for that. But passengers weren't able to release the ramps from the plane, running the risk that the ramps would be pulled underwater along with it. The NTSB recommended requiring quick-release attachments for ramps. The FAA rejected the advice, saying its analysis shows that the attachments were likely to be fully or partially underwater. NTSB said its investigation showed that wasn't the case.

In the movie, immediately after Flight 1549's engines quit, first officer Jeff Skiles, played by Aaron Eckhart, began going through a checklist of procedures for restarting the engines. Pilots are trained to do that in an emergency when they don't know how to fix a problem, but Skiles was only able to get through a fraction of the checklist items before the plane landed in the river.

The NTSB's investigation showed the procedures were designed for a dual-engine failure at a cruising altitude above 20,000 feet, high enough for pilots to complete the list while descending and still have time to regain altitude. But Flight 1549 collided with the geese at an altitude of only 2,818 feet. Among NTSB's closed-unacceptable recommendations are that the FAA require airlines to include procedures for a low-altitude, dual-engine failure in checklists and pilot training.

Continue reading the main story
___
Follow Joan Lowy at http://twitter.com/AP_Joan_Lowy. Her work can be found at http://bigstory.ap.org/content/joan-lowy

Sound familiar? - Except how about 15 years for no response...
Finally I go back to the BB OP on 'Sully the movie'...

Quote:As for Sully, it is a brilliant movie and a must-see for all airline pilots and cabin crew.

It may possibly be one of the best crew training films made. The well-trained and experienced cabin crew performed admirably in their primary function of passenger safety.

It is a shame a movie could not be made about Qantas QF32, the A380 aircraft engine blow-up out of Singapore where the flight crew, under captain Richard Champion de Crespigny, faced a scenario that their simulator training had not covered (this was also the case with the Sully event).

The engine blow-up took out most of the electrical and hydraulic systems, and it was only the professionalism of the crew of the world’s safest airline that managed an extraordinary feat of airmanship in landing the aircraft safely back at Changi airport.

The ATSB should realise that the opinions of armchair experts, mathematical modelling and simulations do not stack up against the real-world experience and knowledge of professional airline pilots.

MTF...P2

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RE: The search for investigative probity. - Peetwo - 09-19-2016

On the flip-side Downunda -

Compare the above to our 'not so famous' survived jet ditching at Norfolk Island December 17 2009. This equally remarkable story of survival had the added degrees of difficulty of being accomplished at night and on the open sea.

Here is a reproduction of Christine Negroni's article on the PelAir ditching which was written prior to the release of the very damning Senate Inquiry findings:

Quote:Upside Down Air Accident Investigation Down Under
February 17, 2013 / 12 Comments

Pel-Air medical evacuation airplane. Photo from ATSB

I am not one to encourage politicians to start sticking their noses into matters of aviation safety. It is WAY too tempting for them to grandstand. But in the case of the Australian Senate and the ditching of a medical transport plane in November of 2009, how could they not?

After all, it is not often that government bureaucrats behave so badly that the politicians wind up looking moderate, but that is just what’s happening in Canberra. Worse, the unfolding scandal seems to indicate that the two agencies that should be more attuned than the average Joe to the complexities of causal chains and the futility of blame in accident investigations have been tone deaf.


Westwind wreckage ATSB photo

Here’s the overview. A medical transfer flight departs from Apia, Samoa to refuel en route to Australia, at Norfolk Island, a wee spot of hilly terrain east of Australia’s Gold Coast. It is a long, over water flight made more challenging by the fact that en route weather and visibility at the arrival airport are deteriorating as the flight progresses. For a number of reasons, (which you can read about from AvWeb here if you are so inclined) this escapes the notice of the crew until they are past the turn back decision point.

After four missed approaches with little fuel remaining, the pilot opts to ditch the Israel Aircraft Industries twin jet Westwind 1124A into the ocean and happily, everybody survives and is rescued.

The Australian Transport and Safety Bureau report, which takes nearly 3 years to complete, essentially attributes the accident to inadequate crew planning and decision making. There’s a teeny tiny peek up the chain when in what is referred to parenthetically as a “minor safety issue” the report suggests the operator “did not effectively minimise the risks associated with aeromedical operations to remote islands.”

In a nutshell, the ATSB pinned the accident on the pilot. Except in this case the pilot, Dominic James, poked back.

I don’t know how politics works in Australia; Capt. James got someone’s attention, some questions were asked and darned if two members of Parliament, David Fawcett and Nick Xenophon don’t start asking questions, too. Over the past several months the startling answers are beginning to emerge. Turns out Pel-Air, the operator for whom Capt. James was flying that night, had been a subject of concern to the Civil Aviation Safety Authority, specifically for its shortcomings in pilot training and fatigue risk management. Both of which were issues in the air evac flight. 

This is discovered because after the accident, the regulator commissioned an audit of the operator and (Kudos here!) a review of its own oversight.
 
“It appears as if there were indicators that could have identified that the Pel-Air Westwind operation was at an elevated risk and warranted more frequent and intensive surveillance and intervention,” the report states.  What CASA failed to do was share the results of the audit, called the Chambers Report with the ATSB.  It probably would have broadened the ATSB’s narrow conclusions about the accident.


> John McCormick photo from CASA

Confronted with reason to believe the flight crew was only a partial contributor to the accident, the Australian senators called the heads of both agencies into hearings. To John McCormick, director of Aviation Safety for CASA they ask the question, why did you not share with the ATSB, the results of the audit showing serious infractions by the operator of an airplane involved in an accident?

McCormick’s astonishing reply – as reported by Australian aviation reporter Ben Sandilands  – was that McCormick did not consider the information relevant since, the accident was entirely the fault of the captain. 

Though you probably don’t need them, let me repeat that with italics; entirely the fault of the captain. 

I was still trying to fathom how anyone with the title “director of aviation safety” could utter those words when I read his further rationale. The information was withheld from the safety board so as “not to contaminate its decision making.”  Yup, if you keep information from investigators, it won’t affect their decisions, and that’s what we call uninformed decisions. Most folks try to avoid them.

Between the ATSB’s skim-the-surface conclusion in its probe, and CASA’s retro-style, blame-the-folks at the pointy end of the accident, something very strange is going on in Australia’s air safety world. When the guys with the pocket protectors launch in with the double talk and the politicians start to sound reasonable, that’s upside down, no matter what side of the equator you’re flying on.

And again here we are approaching the 7th anniversary of the VH-NGA ditching and what are the lessons learnt??  

Well, except as a lesson straight out of the 'Yes Minister' book of bureaucratic CYA obfuscation tactics, if we refer to the ATSB re-investigation webpage - see HERE - at the last update, apparently not much:

Quote:Updated: 4 April 2016

The re-opened investigation has gathered a substantial volume of additional evidence, primarily from CASA and the aircraft operator, and has involved over 20 interviews with personnel from the operator and CASA, as well as information from the aircraft’s cockpit voice and flight data recorders. Analysis of the large volume of evidence obtained is continuing as is the development of the draft report, which is now expected to be released for review and comment by directly involved parties around the middle of the year. That analysis is focusing on:

•pre-flight planning and fuel management procedures and practices
•in-flight fuel management and related decision-making procedures and practices
•fatigue management procedures and practices
•flight crew check and training
•the operator’s oversight of its flight operations activities
•provision of weather and other flight information to flight crews
•cabin safety and survival factors
•regulatory oversight of activities such as those listed above

The ATSB discovering investigative probity? - Yeah right...


MTF...P2  

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RE: The search for investigative probity. - Kharon - 09-20-2016

P2 has been following the ‘Sully’ saga with great interest, as have we all.  I noted many of comments regarding the NTSB analysis and subsequent salutary lessons for all. It is a very fine thing to see ‘Reason’ and open discussion providing so much food for thought; particularly to the ‘inexperienced’ generation of pilots.  

I mean nothing derogatory by using the term ‘inexperienced’, but throughout aviation history there are those who have had the ‘experience’ of a serious situation and those who have not; well, not in real life anyway. The real thing is an abnormal, rare event in these days of incredible engine performance, wondrous computerized systems, advanced operating techniques and the collective experience of those who have survived that ‘unpleasant’ event.

One of the main reasons for the increased safety levels is that the lessons, some of them bitter, from the past have been analysed and the hard lessons learned.  These lessons have been built into every facet of aviation, from loading baggage to a tricky approach on a bad night with recalcitrant systems.

The one reason we have been able to develop improved safety systems , SOP and the like is due to the efforts of ‘accident investigators’ and the fine work they do. Once the analysis is complete and the conclusions drawn, the lessons are provided, free of charge to industry. Without clear, succinct reporting, analysis and action - based on reports, from both operators and regulators; the accident and incident ratio would be significantly higher. That is an incontestable fact.

The article published in the well respected Airwaysmag – HERE - by Capt. Aux provides two equally important points for consideration.

1) The NTSB report has provided much in the way of ‘lessons’ and presents experienced pilots with ‘new’ thoughts – the ‘how would I’ thought being predominant. In short it makes you think; run scenario’s through your mind, talk to other crew members, run the accident in the Sim, and discuss.  The NTSB report provides something for everyone; everyone learns and the industry gains valuable knowledge and shared experience.  I defy anyone to provide an ATSB report from the past six years which has promoted any ‘learning’ or shared experience of value to this industry.  There has been nothing of value provided in any report which has sparked peer discussion, let alone improved safety. Take Mildura as an example; or the ‘SHEED’ approach into Melbourne. Much chatter among flight crew about what ‘they’ would have done – but not one item of value to that discussion has been provided by ATSB.  Capt. Aux has read and considered the NTSB report and has gained from spending the time.  I read the Mildura report and wanted to throw up.

2) While I’m ‘at it’. I note there is an increase in ‘generational’ incidents and accidents. The old ‘Crash comic’ regularly – once every generation – trotted out words of wisdom and caution for the ‘new’ crews to reflect upon; VMC into IMC; last light; gear up, running on the apron; propellers as shotguns; water in the fuel; carby ice; icing; etc all the little things which were learnt by the previous generation but somehow fail to impress the importance on the newer mind.  The “I learned about flying” articles always created discussion and the pearls of wisdom were polished again, to worn by the new generation.

These topics are the prime responsibility of the ATSB, getting the message out, in a timely manner and providing the bare bones of a case for consideration after a preventable event; even an unpreventable one, such as Sully’s. Without factual and operational analysis, supported by an ‘expert’ body, the lessons will be diluted or ignored.  Mildura was a very close call as are many of the other ‘events’ which were provided by the ATSB soft shoe shuffle sytstem

Bravo NTSB, well done Capt Aux. Shame on you ATSB and your ‘Beyond all Reason’ PC approach to reporting and recommending. Read the Aux article, read the NTSB report; see the difference and lift your bloody game back to a world standard.

Toot - toot

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RE: The search for investigative probity. - Peetwo - 09-26-2016

Ghost who walks & talks beyond Reason-

Off the selfie-King & miniscule Dazzling Dazza's thread, a full boiler post from the Ferryman... :

(09-26-2016, 08:50 AM)kharon Wrote:  Full Steam GD.  Pour it On.

Damn the guns and hammer the engines – we have an urgent pick up and delivery mission.

Made a routine ‘how gozit’ call Karen Casey, see what was new and how things were progressing. On the positive side Sen. Cameron has taken an interest in the matter and there are positive signs from that. Here endeth the good news.

To business: stunned is the only way I can describe my reaction to the following; incredulous followed, then fury. Plain old fashioned outrage, in spades, redoubled.  It goes like this, paraphrased for brevity.

KC rings ATSB – Walker, to see when the second ATSB report may emerge from deep sleep chamber.

Walkers response was unbelievable; but notes and a statutory declaration take the matter to truth. In short, he was rude and aggressive. Statements like “Karen, just what do hope to gain from this report” “What do you want to get out of it”.  “It is your fault there is a delay”.  The whole debacle seems to be Karen’s fault all of a sudden and the ATSB is offended; etc. grossly miffed.

It was not Karen’s fault the aircraft ditched; it was not Karen’s fault she got badly hurt and it most certainly was not Karen’s fault that the ATSB and CASA got caught sweeping the whole thing under the table; nor was it Karen’s fault that Albo dived out of the back door as soon as the smoke alarum went off.  Karen had little to do with the Senate findings and the pasting dished out to both ATSB and CASA was well deserved. They got away very lightly, considering.

None of this is any excuse for being rude to anyone. Who the duck does Walker think he is? ATSB should be calling for his resignation.  No matter who rings with a genuine concern no one should be treated in the manner Karen was.

What chance a honest report when the man in charge turns out to be a coward and a bully?  Those types, when under pressure and attempting to justify that which cannot be justified habitually turn out to be not only disingenuous but happy to offset the blame to anyone else they can.

If the Walker attitude reflects the ‘new’ ATSB approach to victims of air accident then it is time for the minister to step in. I know that had I spoken to anyone in the workplace in that manner, my head would be following my arse out of the door before I could say ‘Sorry’.

If Walker won’t resign, then the minister needs to act, swiftly.  Fair warning, this is not going away.

A metaphorical head in basket is demanded: I don’t care how it gets there.

I cannot properly express the full measure of contempt and disgust this story has generated. The Pel-Air charade was a national disgrace; mentally kicking an accident victim when they are down and struggling to get through life with pain and grief is beneath contempt, particularly when the thread which keeps Karen attached to this world is tenuous, even on a good day.

Lets go and pick up this prick GD; seems he is late for his appointment with the Boss.

More to follow - bet your life on it.

Toot – bloody – toot.

As you would expect when someone has just been bumped up to PAIN public enemy No1.; down the pipe came the order for me to cyber-troll and re-visit the PAIN archives for any scurrilous dirt on the infamous black-box whisperer and the man who believes the causal chain for accidents, for example QF1's embarrassing runway overrun at Bangkok in 1999; or the Lockhart River tragedy, can be simply explained through a 'cloud association' diagram.

Here is Walker's cloud diagram for the Lockhart River causal chain:


 

 (Hint: take note of dates) This is where it starts to get interesting because that diagram was extracted from a research paper that was co-authored by Walker and the former ATSB CEO Kym Bills, which was subsequently published in 2008 (P2 - note the research paper title): Reference - AR2007-053 

Quote:Analysis, Causality and Proof in Safety Investigations

Summary

The quality of a safety investigation's analysis activities plays a critical role in determining whether the investigation is successful in enhancing safety. However, safety investigations require analysis of complex sets of data and situations where the available data can be vague, incomplete and misleading. Despite its importance, complexity, and reliance on investigators' judgements, analysis has been a neglected area in terms of standards, guidance and training of investigators in most organisations that conduct safety investigations.

To address this situation, the Australian Transport Safety Bureau (ATSB) developed a comprehensive investigation analysis framework. The present report provides an overview of the ATSB investigation analysis framework and concepts such as the determination of contribution and standard of proof. The report concludes by examining the nature of concerns that have been raised regarding the ATSB analysis framework and the ATSB's consideration of these concerns.

The ATSB believes that its investigation analysis framework is well suited to its role as an independent, no-blame safety investigation body. It is hoped and expected that ongoing development and provision of information about the framework can help the safety investigation field as a whole consider some important issues and help develop the best means of conducting safety investigations to enhance future safety.

Type: Research and Analysis Report
Author(s): Michael B. Walker and Kym M. Bills
Series number: 2007053
Publication date: 26 June 2008
Publication number: 08196
Related: Human factors
 



Last update 07 April 2014

In the lead up to that research paper Walker also made a presentation to an ISASI seminar in Mexico 2006 - see page 10 HERE:

Quote:...In recent years, the ATSB and other safety investigation agencies
successfully used the Reason Model of organizational accidents
(Reason 1990, 1997) to guide the analysis phase of some investigations.
Although the Reason Model is widely accepted, some
of its features limit its usefulness. The ATSB has adapted the Model
to better suit the requirements of safety investigation and to make
the Model more applicable to a wider range of investigations.
The primary changes to the Reason Model include broadening
the scope beyond a focus on human factors, and to more functionally
define the components of the model so as to reduce overlaps and
confusions when categorizing a factor. In particular, ATSB’s model
clearly distinguishes between the things an organization puts in place
at the operational level to minimise risk (i.e., “risk controls” such as
training, procedures, warning alarms, shift rosters) and the conditions
that influence the effectiveness of these risk controls (i.e., “organizational
influences” such as risk-management processes, training
needs analysis processes, regulatory surveillance)... (P2 - Hmm...that sounds familiar -  
)

And that is when I had a light bulb moment because some of the wording in that Dr W presentation and his 2007 report, reminded me of a tabled ATSB email from the Senate Inquiry which always perplexed me as being somewhat out of context and in conflict with other ATSB evidence tabled...



 

 
Now I know it is not a 100% guaranteed that the redacted document is from Dr W but if it is not him then it is certainly one of his BASR converts...  

Therefore I now believe that Dr W is in fact the bureau version of Hoodoo Voodoo (i.e. Dr A) and was the primary motivator for Beaker launching and adopting his 'beyond (all sensible) Reason' methodology. Which ironically IMO means Dr W is part of the 'causal chain' in the diabolical original Norfolk Island VH-NGA ditching accident investigation and the now approaching 2 year re-investigation...

Combined with the discovery that Dr W is also a Sociopath (Ferryman post) and speaks with forked tongue, has to represent the biggest conflict of interest for this parasite to be anywhere near the PelAir re-investigation, let alone the Investigator in Charge...FDS!    


MTF?- Definitely...P2  

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RE: The search for investigative probity. - P7_TOM - 09-26-2016

Apology ? put it where the sun don’t shine.

P2 is not the only one to be trawling the archives; from Lockhart to Pel-Air.  I dug out the PAIN submission to Senate on the inquiry; the supplementary raised many unanswered questions. I believe it is time that the whole truth and nothing but was dragged out, in public, and placed squarely at the minister’s door.

Walker is another ‘head –in-the-clouds academic; proving esoteric, publishable theory for ‘academia’ not for the practical, hands on world of aviation; particularly the accident investigation arena.  The arrogance of the creature; Reason (warts and all) has been a useful tool for investigators world wide; tried and tested in many investigations, the results of which, I might add, have enriched aviation. The Walker version of Beyond all Reason has produced a string of half assed, inutile non-reports culminating in a Senate Inquiry into the bloody awful shambles of the Pel-Air inquiry.  This turnip has much to answer for, Australia’s international reputation as a first class accident investigator for a start; the MH370 pantomime killing off any hope of redemption.

Then, just to top all this off – this (deleted) thinks he can growl and bark at our Karen; with impunity. Well he may well have screwed the pooch with cloud cuckoo land notions of what an investigation should be; but he has created a major problem for himself and his minister by insulting Karen. She’s a ducking victim you halfwit, suffering much, for a long period, mostly through the atrocious handling of the Pel-Air incident.

A printed, public apology may satisfy the spin doctors and word weasels. But not me.  I have a particular way of dealing with bullies, cowards and those who think they are entitled to pick on those who cannot defend themselves; walk into our pub one night; you shall have a not too much theory, practical demonstration. No trouble, happy to see you. Twat.

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RE: The search for investigative probity. - Gobbledock - 09-26-2016

C'mon Ferryman, gimme 2 minutes with this pond scum. Please?????

Disgusting puerile abhorrent slice of rodent shit! Hey Dr Walker - go smoke a cyanide pill you piece of $2 trash!
Just another bureaucratic wanker who thinks that because he has a PHD it means that his shit doesn't stink and that he is above everyone else in the intelligence stakes. News for you Doc - you are nothing more in life than a mere mortal with a high I.Q, giant ego and tiny set of plums. The last time you got your fingers dirty mate was when you were using them to get a leg up the ATsB ladder. PHD? Big fucking deal! You pathetic worm, grow a set and go and pick on a bloke your own size or a Gobbledock. You spineless Canberra dwelling layer of dross.

Karen Casey was an unwilling victim - wrong place at the wrong time. Nothing more and nothing less. A career nurse who chose an admirable self sacrificing career that assists those in need, a career where care, compassion and empathy for other humans comes first, exactly the opposite to a bureaucrat or political parasite.

However, to answer Walkers question on behalf of Karen, if I may;
He said, "Karen, what do you hope to achieve"? My answer; "NONE OF YOUR FUC#KING BUSINESS".

The nerve of this turd, who the hell is he to ask? Does he think it's all about him? Does he think he has the right in life to question Karens motives, whatever they are? Jesus. Someone sack this worm. Isn't it a prime example of the level of narcissism and sociopathy that Beaker, Hood, Walker, Walsh and others have displayed at a senior level in the same organisation?

This is a disgrace. I can only hope that the good Senators are sharpening their Senate pins and preparing to jam them through the eyeballs and up the arse of a Dr Walker doll. Line em up Senators, make these maggots squirm and please feel free to unload onto them lock, stock and smoking barrel. Stick that on your effing ATsB page morons........

Thoroughly disgusted.

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RE: The search for investigative probity. - Kharon - 09-27-2016

Hiatus; after the storm.

I quite enjoy a full head of steam, most refreshing, but I do however like to know the root cause. When I got the whole story from Kaz; the blue touch paper started to fizz; certainly the Walker insulting, demeaning behaviour and unbelievable ‘attitude’ created the spark, but I was surprised at the level of fury it generated. Time to think it through; so I did.  Ala P2, I put on the research hat, fired up the trusty box, grabbed a fresh ale and went back to the very beginning.  From Seaview to Lockhart through to Pel-Air; Mildura, Albury, Melbourne etc.  The midnight oil bill took a beating, I finally understood the radicals, but not the Walker trigger. A second ale helped sooth the curiosity bump and the little light came on. The Pel-Air review, the itch I couldn’t scratch.

Totally and completely unnecessary. The Senators (bless) allowed a second chance; with which I have no quarrel; they could hardly take an axe to the entire structure of aviation administration, much as they may like to. So, as an act of grace and forbearance, a second chance was gifted. A chance for both the ATSB and CASA of redemption, an escape from the pit.  Furry muff, I can, as a practical man accept that. What I cannot accept is that both agencies have continued, despite a very close shave, to thumb their collective noses at government and industry alike. That attitude clearly reflected in the Walker diatribe against Karen Casey. In a few short moments, he revealed the true attitude of the agency he represents.  Karen, like industry, is an irritant and may be treated with open contempt. There is not a hint of ‘humble-pie’ or apology, not a scrap of remorse, not a glimmer of real change to be seen. In short, despite Pel-Air there is no hope of a real attitude change, in fact quite the reverse. They are coming out swinging, not in a mans way, but with snide, smug, self satisfied work round’s, of which they are ‘proud’.

The concerns PAIN raised in supplementary comments, provided to the SSC on the re-investigation of the Pel-Air incident are proving to be founded in reality. Walker’s attitude indicative of fact.

FWIW – the Supplementary comments are available from the AP library – HERE -.

P7 is correct. A weasel worded apology will not serve, the under pinning structure is deeply flawed and an attitude change is necessary. Anything else is simply window dressing, designed to keep the ministerial arse out the public sling.  Warning – that will not be allowed to happen; not a second time.

Toot – toot.

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RE: The search for investigative probity. - Peetwo - 09-29-2016

Importance of IP lies in the lessons learnt -

Paragraph 3.1 of ICAO Annex 13 states:

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents...

Unfortunately this fundamental principle of learning from others mistakes or contributory factors to a mistake leading to an accident/incident seems to have been lost in the world of bureaucratic CYA obfuscation & self-preservation.

The following blog piece, courtesy of Captain Aux, brings back to ToRs the purpose of effective AAI and investigative reporting... : 

Quote:

Memories, Not Dreams…

• September 27, 2016
  

Quote:” Learn from the mistakes of others – you haven’t got time to make them all yourself.”Jules Tapper

Folks, I recently read a wonderful aviation book that any discerning aviation fan would devour. Entitled, “Memories Not Dreams” (Amazon kindle, $3.95) it is a wonderful collection of true short stories from one of the original pioneers of New Zealand aviation, Jules Tapper.

Author Tapper navigates his helicopter through the rugged passes of southeastern New Zealand.

Author Tapper recently contacted me after reading my “There I Wuz!” series, and invited me to read his book.

Written in a similar format of true short stories, “Memories” tells many tall but true tales of his life in the untamed skies of the New Zealand Outback. Tapper is one of those rare breed of “been there done that” pioneer bush pilots who lived by his own rules and that of Mother Nature, and forged his own path, in a time when few had ventured into the wilds of New Zealand. An airplane owner at age 17? Now, that’s one adventurous spirit!

As Tapper notes in his “Risk-Taker’s Creed”:

“The person who risks nothing, does nothing…only a person who risks is free!”

Tapper’s nephew, Mike, lands on a grass strip in the NZ Outback.

Each short story comes with a liberal dose of humility, humor, and sobering lessons learned, in a time when few rules applied, other than the rule of survival by the seat of one’s pants.

Oh, and with plenty of dynamite to go around as well!

Fellow pilots would be wise to learn from Jules’s mistakes, ingenuity, fortitude, triumphs and misadventures. Indeed, after reading his book, I enthusiastically requested to print one of his stories in our next “There I Wuz” Volume. He magnanimously agreed. Now, my quandry is, Which of his wonderful tales to tell?

Recommended for any adventurous spirit who wants lively, colorful aviation tales, well-told.

Link: www.amazon.com/Memories-not-Dreams-Jules-Tapper-ebook/dp/B00FTIX8YS

Quote:The freedom we enjoyed in the days before bureaucracy caught up with us will always remain in my memory. - Jules Tapper

Author Tapper and his beloved Tiger Moth—before the prop spun off inflight!

Book Description from Amazon

 

‘Aviation adventurer with a briefcase’ is one way of describing Jules Tapper. A 4th generation Southlander, he cofounded his own bush flying operation in Fiordland, New Zealand.

  He has flown over 100 different types of aircraft, helicopters, gliders and paragliders over 5 decades and is still actively flying in all disciplines. In 2010, he was conferred an Officer of the New Zealand Order of Merit for his long service to aviation & tourism.

From the Author

 

Many people involved in aviation do not realise that they hold huge amounts of information and practical experience that may be of great assistance to those coming through the system.

  I have always felt it incumbent upon me to share both the good and bad experiences in life because as an old flying instructor said to me many years ago, “Learn from the mistakes of others – you haven’t got time to make them all yourself.” Sound words that I have never forgotten.

When I look back on what has been a mostly adventurous trip through a lifetime involvement with aviation, extensive travel, tourism and business, I reflect that I have had quite an extraordinary and generally fortunate run. This book is the result.

  Enjoy the ride, and remember: you only get one cut at life. Live it to the full and have no regrets. It is great when you can truly say “Non, je ne regrette rien” ( No, I have no regrets.)

—Jules Tapper ONZM author of ‘Memories not Dreams‘.

That link again: www.amazon.com/Memories-not-Dreams-Jules-Tapper-ebook/dp/B00FTIX8YS

Oh, and, for the record, Jules’ instructor was quoting one of my all-time favorites:

MTF...P2

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RE: The search for investigative probity. - Peetwo - 10-18-2016

Finally some Reason in the ATSB nuthouse -   


Reference the Senate thread on latest bollocks PelAir update:

(10-14-2016, 08:07 PM)Peetwo Wrote:  [quote pid='5471' dateline='1476405150']
..Two days ago DIPs to the 2nd PelAir cover-up/cock-up ATSB investigation were informed by Dr (Beyond-all-Reason) (I've a conflict of interest) Walker that there would be a further public update issued on the progress of the 'RE'-investigation.

Well again without absolutely any recognition (i.e. update to the aviation investigation page, media release or tweep from the twitter guy) the ATSB discretely by stealth released an update eight in what has to be the longest running ICAO Annex 13 AAI in the history of the world??

Quote:Updated: 13 October 2016

The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen.  However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry.  The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year.  Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.

    
No further comment required - UDB? No actually totally ducking believable...

Update: Ben Sandilands (Plane Talking) with a summary of the nearly seven year diabolical saga of the VH-NGA Norfolk island ditching:  

Quote:After almost 7 years Pel-Air crash scandal lurches toward finality
Oct 14, 2016
Ben Sandilands

How the ATSB expunges the shame of its original and highly unprofessional inquiry into the Pel-Air ditching remains to be seen

The wreckage of the Pel-Air jet which the ATSB originally refused to recover

Comments from Tango onwards -

Quote:Tango

Ben: Could you give a short synopsis of what deficiency specifically the regulatory authorities played in this that should have been different?

I know this has been commented on, but I continue to wonder about the Airlines part and not the Australian regulatory end.

But I also wonder about the so called Medevac period. The patient survived a ditching, spent 90 minutes in the water and lived. What condition of the patient required a Medevac?

And I don't care what the regs say or not, you don't fly a one way trip assuming you do not need to be able to divert.

I can't pierce the timeline together enough to figure out if they could have returned to Apia when they found there was an issue with deteriorating weather (it sounds like they would have had a significant tail wind)

I would place the vast majority of the extremely poor judgment on the Pilots head as well as Pel-Air. They did not have it in regs for divert fuel does not cut it with me.

Credit to the pilot that he did an outstandingly good job ditching it. While his judgment was abysmal (and despite that, he also made the right decisions to ditch in time so its some and some) , his flying skills and aircraft knowledge were obviously first rate. If I could get his judgment up to speed I would hire him in a heartbeat.

I have not read the specific detail of evac, but it appears the crew did a good job on getting everyone out of the aircraft as well.

I do find a fault that those actions are not in the report, it should always include what was done right ( even if bad decision led to the situation) as that is a lesson for all about how to go about that part correctly.
 

---

James Wilson

Tango,

I agree - operating to a remote island destination without sufficient fuel for an alternate was unwise, even though it was allowed by the regulations. The TAF the crew was issued before departure indicated the weather was expected to be good at their ETA for Norfolk, but the weather in that area is known to be unpredictable and difficult to accurately forecast. I guess inexperience, lack of training and poor operations manual guidance all played a part.

To complicate matters further, the aircraft was only marginally suitable for the route it was operating because it was not RVSM compliant. That meant that ATC could force the aircraft to descend to a level below RVSM airspace in the event of a traffic conflict. The flight in question was asked by ATC to descend to FL270 for that reason, but the crew was able to secure a higher level. Ironically, if they'd been carrying more fuel they would have had to descend because they would have been too heavy for the higher level. They would then have burnt far more fuel and been no better off for carrying the extra fuel.

Regarding the PNR, I think you'll find they were well past the PNR for Apia when the weather deteriorated. The crew didn’t appreciate the deteriorating weather until they were near or possibly past their last point of safe diversion for Noumea, which was the last enroute alternate that was available to them. By that stage, the crew was unsure if they had sufficient fuel for Noumea, so they elected to continue to Norfolk.

The ATSB stated that the carriage of main tank fuel only, as occurred on this flight, meant that if the aircraft had suffered a depressurisation (the most critical scenario) at the least favourable position during the flight, it would not have had sufficient fuel to fly to a suitable alternate. That alone was a significant breach of the rules.

I don't think any information has been released regarding the the medevac patient's condition, probably due to medical privacy issues.

The difference in the regulations for this flight related to the "aerial work" category. Passengers can be carried on aerial work flights such as medevac, but they are not carried for hire or reward. I guess the theory was that you take your chances if you’re not paying a fare. The regulations have since changed.
 

---

Ben Sandilands

James and Tango,

I just can't stop working on other things to elaborate on all of those points, although I have covered off on them in the past. (This solo, unpaid game has some limitations.) However the patient passed away some seven to eight years after the crash. In the short term she suffered considerably from the immediate aftermath, and had settled litigation brought against the operator Pel-Air and/or its owner REX.

It is a disgusting reflection on the authorities and Ministers Albanese and Truss that no government made a point of actively pursuing justice for all concerned, and in my opinion, showed no signs of doing anything but taking instructions from civil servants who I think held each of them in total contempt anyhow. As senior civil servants tend to do of Ministers in Canberra. The executive branch has basically been (withheld graphic epithet) by the administrative branch in aviation safety in this country since the latter part of the 90s. 

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Ben Sandilands

Tango,

I should have earlier mentioned that the pilots of large jet airliners aren't require in this country to fly with sufficient fuel to reach an alternative airport if on arrival in the vicinity of their destination they are unable to land because of a deterioration of conditions (and quite possibly a few missed approaches etc). This was the situation in the Mildura fog fiasco in 2013. Neither 737 could have made it to a suitable alternative airport from Adelaide approach airspace, and it was that situation that saw them take advice to divert to Mildura before committing to a descent to the SA airport, only to discover how bad the situation was at that rural airport.

We have in this country an ingrained policy of "she'll be right mate" when it comes to fuel rules, and if it wasn't for the innate conservatism of some pilots in loading extra fuel for domestic flights the risk of a much worse outcome than seen at Mildura would probably have taken a planeload of lives before then. I'm aware of stories of a few mainline jet diversions to country airports, including one where the runway itself was marginal, that could have ended very badly. I do not see any evidence that CASA, or the airline managements, have the slightest intention of introducing or supporting the safer fuel requirements that apply to airline operations in the US and some other wiser jurisdictions when it comes to fuel planning requirements.

---

James Wilson 

 Just to clarify that Ben, they're not required to carry fuel for an alternate when the weather is forecast to be above the alternate minima. The alternate minima provides a buffer above the landing minima to cater for unforecast deteriorations in the weather. The problem of course, is when significant deteriorations occur that aren't forecast, as happened at both Norfolk Island and Mildura. On another note, a bunch of previous posts seem to have been deleted. Touchy subject, eh? 

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joe airline pilot October 18, 2016 at 6:57 pm

As James Wilson explains, your point is not quite correct. The rules are clear around requiring an alternate airport any time the weather conditions deteriorate below a defined criteria. Whilst it may be true that a destination does not require an alternate at the time of departure, that doesn't mean that the pilots adopt a cavalier attitude and just blast off hoping for the best. There is an enormous amount of planning that goes into a flight, before and during. That means planning for failures that increase fuel burn, assessing critical points and pnr's for enroute alternates and updating weather during the flight. That's the difference, and the reason why in one case a crew landed a jet safely and the other ended up in the water.The bulk of a pilot's job so threat and error management, this means planning. 

---

Ben Sandilands

October 18, 2016 at 8:07 pm

Joe,

That was made perfectly clear in the original posting on the Mildura incident. It was also made clear in the coverage of the cop-out ATSB report and the incidents themselves that your perfect world of professionalism explanation fails to cover when two 737s found themselves with no-where to go but a fog bound country airport. I live in the real world, this was a serious incident, as numerous other pilots made said here and in technical forums, the deficiencies in those rules saw one 737 with almost no fuel left to set down by guesswork or intuition over a runway the pilots couldn't see.

Why are you making such perfect world excuses for the inexcusable? And why have you forgotten what was reported at the time? I don’t think the majority of your colleagues agree with you on this.

Now with all that in mind I was intrigued to find a very much related ATSB news item released today that almost (but not quite - ) mentions the Mildura cock-up and PelAir cover-up in the context of an ATSB Officer's soon to be conducted research paper:

Quote:Ground-breaking aviation research to reduce unforecast weather risks

ATSB senior research analyst Dave Wilson is working on a research investigation that will raise awareness of potential weather-related risks among pilots and also examine the effectiveness of rules that have been in place for more than 30 years.



Weather planning rules in Australia are unique compared to countries in Europe and North America. Because weather in Australia is generally good, risks are very low. But when weather is unsuitable for landing, these differences can have a real world effect on aircraft operations. It is these effects that Dave’s research aims to quantify.

A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding and, in some cases, landing below published safe limits. Dave’s research is seeking to understand how the reliability of weather forecasts affects the ability of flight crew to conduct safe landings.

“I want to help decrease the likelihood of pilots being exposed to unexpected and unsuitable conditions for landing,” Dave said. “The likelihood of an accident happening because of conditions unsuitable for landing is low. But in making it even lower, the probability of a major accident happening reduces considerably.

“Initially I’m looking at Mildura and Adelaide airports. At Mildura, 99 per cent of the time, the weather is suitable to land a large aircraft. But based on the data I’ve looked at, there is still a remote possibility you may have an unreliable forecast. With the volume of air traffic, this could affect up to four aircraft per year.

“If you look at Adelaide, the chances of a single flight crew being exposed to an unreliable forecast are lower. However, when you take into account fluctuations in weather reliability, and the aircraft traffic arrival patterns (around 50,000 per year), the potential to result in a catastrophic accident increases. That’s what we want to avoid.

“If you’re in the air and you get to the point of last safe diversion—where you’ll be committed to landing at the planned destination—if the current forecast predicts marginal conditions, questions are raised as to whether continuing to the planned destination or diverting to an alternate destination should be required. This scenario has been a particular focus of this research.”

Dave has a vested interest in his research. Several actually. He’s a pilot who first flew solo when he was a 15-year-old student at Caringbah High in Sydney—well before he could legally drive. The opportunity of subsidised flying with the Australian Air Force Cadets was too good to knock back. He has since flown aerobatics out of Bankstown Airport but has undertaken little flying over past two years while pursuing this research.

Dave also has degrees in Aeronautical Engineering and Physics from Sydney University. It was there he attended a guest lecture by Pierre Blais from the Directorate of Defence Aviation and Air Force Safety (DDAAFS), which set him on a path to the ATSB.

“It was then that I thought investigating aviation safety would provide the ultimate career path for me. I find it both meaningful and challenging,” Dave said.

The research was initially going to secure Dave a Master’s degree. But he is now upping the ante and aiming to pursue a Doctorate. A stumbling block is finding reviewers with sufficient expertise in a related field. When you’re breaking new ground, this is often the case.

After first working at the Department of Infrastructure as a vehicle compliance engineer, Dave came to the ATSB to embrace his love of aircraft, engineering and how things work. Now with six years under his belt, Dave is also considering his future. “I’m happy as long as I’m being challenged,” he said. “But after this research is completed, I wouldn’t mind also undertaking a broader range of transport safety investigations.”

Research on Adelaide and Mildura aerodromes is expected to be published by the end of 2016. Progressive reports for each major aerodrome in Australia and four of our remote island aerodromes (Norfolk, Cocos, Christmas and Lord Howe) will be progressively released over the next year or two.
 



Last update 18 October 2016 

    
No direct criticism of Dave here, however I find it deeply disturbing that it has taken 16+ years with an identified (normalised deficiency) safety issue that has been causal to a number of min fuel occurrences & accidents, and we are just now exploring the regulatory  and BOM contributory factors that are part of the causal chain to these incidents and accidents...


MTF...P2  
[/quote]

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RE: The search for investigative probity. - Peetwo - 10-24-2016

Hunter reshape for Hoodlum & the invisible Manning??

Gobbles: "..And P2, this time bring your long-johns please, no spooning allowed on this trip, Hoody isn't coming along..."

Not fair GD now Hoody is King Dick at the bureau he is getting much better offers..

Hardly blame him, who wouldn't take hobnobbing in the Hunter, with the likes of Harfwit & Wingnut, over scaling Mount NCN...
   
Reference the RAAA thread:

(10-24-2016, 06:03 PM)Peetwo Wrote:  In case you were wondering who - besides Carmody - was present from the government and the alphabet soups, here is the programme for last Friday at RAAA convention:

Session 9
09:30 - 10:00
Greg Hood / Chris Manning
Chief Commissioner / Aviation Commissioner
Australian Transport Safety Bureau

Reshaping

P2 - Well that explains why Hoody didn't volunteer turning up for his Estimates session on Friday...   Wonder if someone got any photographic evidence of the invisible Manning actually being present; & what the hell is RESHAPING...   

Hmm...perhaps reshaping has a similar meaning to 'match fit' or 'TOGA' -



Moving on, I see that Hoody took the opportunity of being dismissed early from Estimates on Monday to catch up with a bit of paperwork and in the process actually filed an ATSB report that was not overdue... :

Quote:
Download complete document
[ Download PDF: 3.78MB]
 

Still reviewing to see if it was 'obfuscated' but couldn't simply go past Hoody's review without a) LMAO and; b) suddenly feeling violently ill...
Here is the first paragraph from Hoody (Warning: Bucket maybe required) :

Quote:
Chief Commissioner’s review 2015–16

This was the ATSB’s seventh year as a fully independent body within the Infrastructure and Regional Development portfolio. 2015–16 also marked the final year of Martin Dolan’s tenure as the ATSB’s Chief Commissioner. While Martin’s real and significant contributions to improving transport safety have been widely acknowledged, it was his passion, energy and commitment to maintaining the ATSB’s reputation as a world-leading safety investigation body that will be remembered as his most enduring qualities...

I am still not sure how to take that absolute BOLLOCKS statement from Hoody, surely he jests...


MTF...P2

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RE: The search for investigative probity. - Gobbledock - 10-24-2016

I filled two chunder buckets by just reading P2's post regarding the ATsB's report opening statement! I am never going to be able to stomach the full Hoodlum report, never! Heaping praise on the safety flaccid Beaker is woeful, it's almost as ludicrous as Hoodster saying that the ATsB is 'independent!! What next? Perhaps they will discover a superior intellectual risk matrix from the 60's written by L. Ron Hubbard?? FFS

And the crowd goes wild, roaring and bellowing, millions in number shouting out BOLLOCKS BOLLOCKS BOLLOCKS BOLLOCKS...........

'Safe glossy bureaucratic spun brochures for all'

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RE: The search for investigative probity. - Peetwo - 11-07-2016

ATSB & AAAA, a partnership of sincerity -

Finally an ATSB news story for Hoody that does not involve dodgy reports, tediously long investigations or MH370 & 'correcting the bollocks'. Nor does it involve CAsA's Pinocchio Gobson authorising the twitter guy to make derogatory comments (see below) on Aerial Ag Ops..  

Background reference:     

Quote:FF cornered rats are biting back -

A tweet from CASA was intercepted earlier today by Phil Hurst CEO of the AAAA's:

Quote:

---

Now why on earth would the Fort Fumble twitter guy feel the need to tweep such inflammatory bollocks, especially when you consider the date of the ATSB MR (16 September) and the paragraph before, the CASA stated statistics, had a much more positive message:

Quote:Wirestrike accidents ongoing concern in aerial application

The Australian Transport Safety Bureau says pilots continue to collide with known wires in aerial application, including agricultural spraying, spreading and firefighting.


The ATSB’s Aerial application safety 2015–2016 year in review found wirestrike was the most common cause of accident and serious incidents in aerial application between May 2015 and April 2016.

Wirestrikes (where an aircraft hits a wire such as a powerline) caused 11 accidents and serious incidents in the 12 month period. Other types of accidents and serious incidents were engine failure or malfunction (6), collision with terrain (3), controlled flight into terrain (2) and runway excursion (2).

Most wirestrikes involve wires that the pilot was already aware of. Often, they involve wires which the pilot has flown several times before that day.

With their flying operations very close to the ground, aerial application pilots are well aware of the dangers of wires. The ATSB says pilots need to know the location of wires in the area to be sprayed through maps, talking with land owners and locals, and through aerial reconnaissance before operations commence.

Spraying patterns need to be organised with the wire locations in mind, and pilots need to maintain focus during their flying task, and use continuous reminders of the presence of wires. When plans change or the spray pattern differs such as for clean-up runs, pilots need to redo their aerial reconnaissance of wires.

Although there has been a slight growth in the number of accidents over the past three years, there were considerably fewer accidents each year in the past decade than in the previous 25 years.

Aerial agriculture has the second highest accident rate per million hours flown across the operation types, behind non-VH-registered recreational aeroplanes.

Aerial application operations are inherently risky, involving low-level flying, high workloads and obstacles such as power lines and uneven terrain.

Read the ATSB research report (AR-2016-022) Aerial application safety 2015-2016 year in review

    
It is also worth reflecting on the following AP posts from the SMH thread, which clearly show that Phil Hurst & AAAA, in partnership with the ATSB are not being complacent and are being clearly proactive in addressing these safety issues:

(07-10-2015, 05:32 PM)Peetwo Wrote:  ...Moving on and I note another 'good news' story coming out of the ATSB, that again does not include the Grandstanding Beaker...hurrah to that!

Quote:Media release

Title

Report to educate aerial agriculture and firefighting pilots
 
Date: 10 July 2015
As aerial agriculture pilots prepare for an early spring start to their busiest time of year, a new ATSB report highlights past aviation safety events in the industry.

ATSB's Manager Reporting and Analysis, Dr Stuart Godley said, 'ATSB has been working closely with the Aerial Agricultural Association of Australia (AAAA) to strengthen their long-standing education and training program by using reported incidents and ATSB investigations to identify key learning opportunities for pilots.

'The statistics clearly identify a long term trend in improving safety in the sector, but both ATSB and AAAA remain committed to improving the safety record even further.

'These statistics should serve as a reminder of the risks these pilots will face during the season that are not present in most other types of flying. Hazards include low-level flying with high workloads and numerous obstacles, in particular powerlines and uneven terrain.

'The good news is that, while these risks are always present, they are generally manageable', said Dr Godley.

The report focuses on aerial application accidents between May 2014 and April 2015 to coincide with the agriculture season in most parts of Australia.

Dr Godley said, 'Wirestrike was the most prevalent type of occurrence with more than half of the total accidents and serious incidents involving a wirestrike'.

Mr Phil Hurst, CEO of the AAAA said, 'We approached ATSB with the idea of producing an annual statement of safety trends in the industry to support aerial application pilots in their ongoing professional development through AAAA’s comprehensive ‘Professional Pilot Program’ and training courses.
 
'This report is a very useful addition to the tools available to professional low level pilots and AAAA thanks ATSB for their practical response in improving access to the valuable safety data they hold.'

There were 13 accidents with one resulting in fatal injury in the preceding 12 months. In total, there were 24 reported accidents and incidents involving aerial agriculture and firefighting operations.

Read the report: Aerial application safety: 2014 to 2015 year in review

Media contact: contact ATSB on 1800 020 616 or Phil Hurst (AAAA) on 0427 622 430

Accolades to Stuart Godley (on behalf of the ATSB) & Phil Hurst (representing the AAAA) for an excellent proactive initiative - & no muppets or CASA in sight...

(07-11-2015, 05:59 AM)kharon Wrote:  Gold stars and no Muppet = Bliss.

Quote:P2 – “Accolades to Stuart Godley (on behalf of the ATSB) & Phil Hurst (representing the AAAA) for an excellent proactive initiative - & no muppets or CASA in sight.”

I think we must go a couple of steps beyond ‘accolades’.  Young Mr. Godley is shaping up as ‘old school’ ATSB and deserves some well earned praise as a bright spot in a dull, drab firmament of endless grey.  He stood his ground very well in Estimates, seems to have a firm grip of his subject and is unafraid to admit to ‘weakness’ in system or method.  Bravo – and thank you for restoring a little faith.

Quote:Mr Phil Hurst, CEO of the AAAA said, 'We approached ATSB with the idea of producing an annual statement of safety trends in the industry to support aerial application pilots in their ongoing professional development through AAAA’s comprehensive ‘Professional Pilot Program’ and training courses. 

Phil Hurst and his crew are consummate professionals, doing a job CASA should be assisting with by developing a tailor made PPP, based on real experience and mitigating the risks they know exist with common sense and good guidance.  The notion to bring in the ATSB was brilliant and once again, Mr. Godley has done the ATSB proud.  This sort of collaboration and cooperation should be made the benchmark for future exercises. Industry expertise combined with specialised ATSB knowledge with one purpose; reducing the risk that someone may not get to the Friday arvo BBQ.  

Quote:'This report is a very useful addition to the tools available to professional low level pilots and AAAA thanks ATSB for their practical response in improving access to the valuable safety data they hold.'

It’s so bloody nice to be able to find a positive step, in the right direction, I’m going to be smiling all day now.  Well done Phil, AAAA and Mr Godley; well done indeed.... .... ........ ........ ......... ........... ......

In the lead up to what is apparently going to be a busy aerial application season, there has already been a couple of aerial agriculture accidents one of which occurred two days ago and was tragically fatal:

Quote:Summary

The ATSB is investigating a fatal aircraft accident involving an Air Tractor AT-502 registered VH-LIK, that occurred near Walgett, NSW on 5 November 2016. The aircraft collided with terrain while conducting spraying operations. The pilot was the sole occupant.

The ATSB has deployed a team of three investigators to the accident site. The team arrived on Sunday and are expected to remain on site until Tuesday. As part of the investigation the team will:

• Examine the aircraft wreckage and site
  
• Collect and review aircraft and pilot documentation
  
• Review weather conditions at the time of the occurrence
  

Witnesses are asked to call the ATSB on 1800 020 616.

 
General details

Date: 05 Nov 2016
 
Investigation status: Active
 
Time: 10:00 ESuT
 
Investigation type: Occurrence Investigation
 
Location   (show map): near Walgett Airport, E 60 km
 
Occurrence type: Collision with terrain
 
State: New South Wales
 
Occurrence category: Accident
 
Report status: Pending
 
Highest injury level: Fatal
 
Expected completion: Nov 2017

Aircraft details

Aircraft manufacturer: Air Tractor Inc
 
Aircraft model: AT-502
 
Aircraft registration: VH-LIK
 
Serial number: 502-0115
 
Type of operation: Aerial Work
 
Sector: Turboprop
 
Damage to aircraft: Destroyed 
 
 


Last update 07 November 2016

 
This has prompted a spontaneous and proactive response from both the ATSB and the AAAA's:

Quote:Safety bureau ramps up warning for agricultural pilots

The Australian Transport Safety Bureau has reinforced a warning to pilots involved in aerial application after a spate of wirestrikes in the past month.

ATSB Chief Commissioner Greg Hood says pilots need to be extra vigilant with the crop spraying season ramping up as we move into summer, with reports of a particularly busy season for aerial agriculture.

“Wirestrikes are always a major issue for pilots involved in aerial application work,” Mr Hood said.

“With this season, it appears to be an even bigger issue. We’ve had five wirsestrike incidents reported to us in the past few weeks. There is no doubt that with an increase in operations, the risk goes up dramatically.”

The ATSB published its Aerial application safety 2015–2016 year in review only last month. It showed wirestrikes to be the most common cause of accidents and serious incidents in aerial application between May 2015 and April 2016.

“Aerial application operations are inherently risky,” Mr Hood said “They involve low-level flying, high workloads and obstacles such as power lines and uneven terrain.

“Pilots have a high workload to navigate these hazards, and have a shorter reaction time if they encounter an issue and need to respond accordingly. But if pilots are working in areas of known wires, the hazard is manageable.”

The ATSB is also investigating a fatal aerial application accident near Walgett, NSW on Saturday, 5 November 2016. The cause of the accident is not yet known.

Safety meetings

The Aerial Application Association of Australia (AAAA) is currently holding Air Improvement Meetings (AIM) for their members around the country. In response to high seasonal demands during the 2015–2016 season, AAAA is holding additional breakfast safety meetings focusing on safety. Wirestrikes will be a key focus of these meetings.
Strategies developed by the AAAA and the ATSB to help pilots manage the risk of wirestrikes include:

• ensuring you are physically and mentally fit to fly
  
• setting client expectations so that they are clear that safety comes first
  
• conducting a thorough briefing and study a detailed map of the area before the flight
  
• conducting an aerial reconnaissance before spraying and conduct an extra aerial reconnaissance before the clean-up run
  
• reassessing the risks when plans change
  
• avoiding unnecessary distractions and refocus when distracted
  
• being aware of vigilance limitations
  
• not relying on your ability to react in time to avoid a wire
  
• actively look for and remind yourself of wires
  
• being aware of and managing pressures
  
• having a systematic approach to safely managing wires.
  

More information
Avoidable Accidents No. 2 - Wirestrikes involving known wires: A manageable aerial agriculture hazard
ATSB research report (AR-2016-022) Aerial application safety 2015-2016 year in review
 



Last update 07 November 2016

Well done Hoody and the ATSB, back to ToRs in partnership with Phil Hurst and the AAAA's -


MTF...P2

---

RE: The search for investigative probity. - Gobbledock - 11-07-2016

ATsBeaker;

Wirestrikes (where an aircraft hits a wire such as a powerline) caused 11 accidents and serious incidents in the 12 month period. Other types of accidents and serious incidents were engine failure or malfunction (6), collision with terrain (3), controlled flight into terrain (2) and runway excursion (2).

Maybe so. However it would be nice to see those figures compared with the amount of ULD loading incidents JQ have had in which incorrect weight and balance calculations were supplied or incorrect loading and positioning of containers including the ones not latched down correctly. A lot more lives put at risk through just one of those incidents than with Ag farmer Bob in his crop duster dodging power lines.

Just sayin.........

---

RE: The search for investigative probity. - Kharon - 12-09-2016

Best Christmas gift ever. From a Pprune legend.

Quote:Stanwell – “Beautiful .. a superb job on those ones.
Yer a legend, Frontal.”

100% spot on – Frontal Lobotomy – posting on Pprune – HERE – has done a bloody marvellous job; not only scanning the Air Safety Digest but has, unselfishly, made them available, free  to all. The highest honour we can give is the golden key to the Tim Tam tin, a life long supply and a well done. In deed, well done that man. Positive safety action – from industry (again). Do yourself a favour - find time to read them - all of them.

Bravo Sir; and, thank you.

---

RE: The search for investigative probity. - Kharon - 12-11-2016

Warning: Longish post.

Half steam GD – but keep it coming. We have work to do this day.

Hood was an important cog within the CASA machinery; he had the juice, but not the balls to deny many of the more fanciful Chambers confections, particularly in regard to both Airtex and Pel-Air. Furthermore when he did finally screw his courage ‘to the sticking point’ he was not concerned about the damage inflicted on industry, but for his own legal position in relation to the documents he had signed. This conflict of interest is not perceived; but very real and very ugly. No matter, the top job at ATSB is now his; the shambles at CASA set aside in the hope that Hood may redeem himself and return the ATSB to a useful agency. The PAIN associates understood the pressures of the McComic years; and, without too much debate, voted to give Hood benefit of the doubt.  

The sickening ATSB response to what are, potentially, serious incidents has ignited fury. For the benefit of our political advisors: I shall try to explain why.

Aircraft wing and tail sections are not ‘voids’ they are places where high tension electrical current, hydraulic fluid at high pressure, hot air bled from the turbine and flight control systems are housed; all crammed together; or, enclosed within inaccessible parts of the aircraft structure. There is a huge amount of jet fuel contained within the airframe; in the wings, in the ‘belly’, even in the tail of the 747 (10 tons of it). Isolated and undisturbed, these systems function beautifully, reliably and extremely safely. They were designed to do this, tested to ensure this, carefully manufactured to standard, fitted correctly and tested, for serviceability, regularly.  The airframe itself is designed to withstand incredible loads and stresses – but not from every direction and can be bent by forces applied in the ‘wrong’ direction – seriously bent.

A ruptured, pressurised hydraulic line can do an incredible amount of damage, it can maim and kill. Same –same a ‘bleed air’ line.  A severed electric cable has the potential to start a fire – even in relatively benign Jet fuel. A damaged external flight control has the potential to have created unseen faults further along the circuit. These are the reasons we try, very hard, not to bump into other aircraft or have other aircraft bang into us. This is not two ladies in four wheel drives having an insurance spat in the carpark. It is a serious event when two aircraft collide; it may, once every second pancake Tuesday happen. But when ‘tarmac’ incidents become a regular events and aircraft are damaged by ancillary equipment; it is time someone got off their arse, found out why and get it stopped.

This, as I see it, is Hoods job. Passing it all off as ‘unfortunate’ and a light contact defines a lack of interest and a subservience to ‘other’ entities. In short; we are seeing the beginnings of the same creature that delighted CASA. I can only agree with the sentiments of both P7 and GD. Fix it or fuck off Greg.

Quote:P7 - Only a ‘twiddle’ as “K” would call it; can't be buggering about with  stats to back it  – but it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?

The statistics clearly define this 'relaxation' – why FDS has the ATSB allowed this to become the unquestioned, norm – unchallenged?  Perhaps Hoody can now earn his corn by answering these questions. I am sick, to the back teeth, of ‘financial expediency’ trumping operational good sense.

Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed); the Kinetic energy, as described by Newton, defies the best run “beyond all reason” model, statistically unchallenged  garbage. It never happened before because it was never allowed to happen – ya duckin' halfwit.

Get real – sort it out; or, alternatively - fuck off.

Quote:GD:-

I've dissected Tom. (I hope it didn't hurt mate?)

Toms twiddle sums up the situation perfectly. I've cherry picked just a couple of points out of it but they are points that on the surface are very basic, but if you dig deep into Tom's comments you will come to some very ugly and concerning conclusions;

Nugget 1;
"it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?"

Absolutely. There were NEVER so many incidents in the pre-LCC days. Back then only a qualified aircraft engineer headsetted an aircraft. Most were 'long in the tooth' Gingerbeers who were accompanied by long serving ground crew in the pushback tug, again many had decades of experience under their belt. It was simply the way it was! Now? Well now you don't even have an aircraft Engineer on the headset with some of our airlines, it could be an ex school teacher or pottery maker with less than a years airside experience doing the headset. And if it is a traditional pushback procedure with a tug and driver, well some of those lads again have a mere year or two ramp experience under their belt. Cost cutting, penny pinching and a total lack of understanding or appreciation of the process and safety risks by executive bean counters has seen the bottom of the barrel well and truly reached. 'Profits before safety'.

Nugget 2;
"Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed)"

The assessment and understanding of this incident by Hoody and/or his investigator through the comment of 'light contact' is again extremely worrying. Firstly, there is only ever 'contact'. Nothing should ever contact an aircraft in a manner it wasn't designed to do, EVER! And to label it 'light contact' is preposterous. Define 'light' Greg? What aircraft 'contact' scale do you measure against? Show us your matrix mate? Actually don't bother Greg, you speak utter bullshit. YOU have made an assumption based on no quantifiable measuring tool, and that is a dangerous precedent for any investigative authority to promote. An investigator investigates and reports using factual evidence, quantifiable analysis, not making up his own personal language or tools, FFS. Also, in the old days just having a set of mobile stairs rubber bumper touching the aircraft would see a pilot or ground engineer rip you a new one! But now, according to Hoody's boys; when you have two passenger aircraft and a wing from one collides with a tail cone of another and damages the shit out of the two aircraft causing a huge amount of damage it is just 'light contact'. UFB. Are these muppets serious?

Nugget 3;
"Get real – sort it out; or, alternatively - fuck off".

Good to see a no holes barred statement as above. Tom sums the ATsB situation up precisely. This level of incident and the subsequent investigation report is a disgrace. Greg, mate, if you can't do the job (and it certainly looks like you are following in Beakers footsteps), please expedite your exit from the building forthwith. In other words, fuck off, NOW.

The ATsB are obviously using the below methodology to determine what is a serious or non serious situation? Enjoy;

---

RE: The search for investigative probity. - Peetwo - 12-11-2016

Hoody: "Pick a trend any trend??" -  

(12-11-2016, 06:07 AM)kharon Wrote:  Warning: Longish post.

Half steam GD – but keep it coming. We have work to do this day.

Hood was an important cog within the CASA machinery; he had the juice, but not the balls to deny many of the more fanciful Chambers confections, particularly in regard to both Airtex and Pel-Air. Furthermore when he did finally screw his courage ‘to the sticking point’ he was not concerned about the damage inflicted on industry, but for his own legal position in relation to the documents he had signed. This conflict of interest is not perceived; but very real and very ugly. No matter, the top job at ATSB is now his; the shambles at CASA set aside in the hope that Hood may redeem himself and return the ATSB to a useful agency. The PAIN associates understood the pressures of the McComic years; and, without too much debate, voted to give Hood benefit of the doubt.  

The sickening ATSB response to what are, potentially, serious incidents has ignited fury. For the benefit of our political advisors: I shall try to explain why.

Aircraft wing and tail sections are not ‘voids’ they are places where high tension electrical current, hydraulic fluid at high pressure, hot air bled from the turbine and flight control systems are housed; all crammed together; or, enclosed within inaccessible parts of the aircraft structure. There is a huge amount of jet fuel contained within the airframe; in the wings, in the ‘belly’, even in the tail of the 747 (10 tons of it). Isolated and undisturbed, these systems function beautifully, reliably and extremely safely. They were designed to do this, tested to ensure this, carefully manufactured to standard, fitted correctly and tested, for serviceability, regularly.  The airframe itself is designed to withstand incredible loads and stresses – but not from every direction and can be bent by forces applied in the ‘wrong’ direction – seriously bent.

A ruptured, pressurised hydraulic line can do an incredible amount of damage, it can maim and kill. Same –same a ‘bleed air’ line.  A severed electric cable has the potential to start a fire – even in relatively benign Jet fuel. A damaged external flight control has the potential to have created unseen faults further along the circuit. These are the reasons we try, very hard, not to bump into other aircraft or have other aircraft bang into us. This is not two ladies in four wheel drives having an insurance spat in the carpark. It is a serious event when two aircraft collide; it may, once every second pancake Tuesday happen. But when ‘tarmac’ incidents become a regular events and aircraft are damaged by ancillary equipment; it is time someone got off their arse, found out why and get it stopped.

This, as I see it, is Hoods job. Passing it all off as ‘unfortunate’ and a light contact defines a lack of interest and a subservience to ‘other’ entities. In short; we are seeing the beginnings of the same creature that delighted CASA. I can only agree with the sentiments of both P7 and GD. Fix it or fuck off Greg.

Quote:P7 - Only a ‘twiddle’ as “K” would call it; can't be buggering about with  stats to back it  – but it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?

The statistics clearly define this 'relaxation' – why FDS has the ATSB allowed this to become the unquestioned, norm – unchallenged?  Perhaps Hoody can now earn his corn by answering these questions. I am sick, to the back teeth, of ‘financial expediency’ trumping operational good sense.

Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed); the Kinetic energy, as described by Newton, defies the best run “beyond all reason” model, statistically unchallenged  garbage. It never happened before because it was never allowed to happen – ya duckin' halfwit.

Get real – sort it out; or, alternatively - fuck off.

Quote:GD:-

I've dissected Tom. (I hope it didn't hurt mate?)

Toms twiddle sums up the situation perfectly. I've cherry picked just a couple of points out of it but they are points that on the surface are very basic, but if you dig deep into Tom's comments you will come to some very ugly and concerning conclusions;

Nugget 1;
"it seems to me that ‘push-back’ and ‘ground’ incidents’ have been on the increase for a while now. There is a distinct pattern in the ‘dots’ which suggests something has changed. Before the bottom line became so much more important than common sense; there were not so many touchy-feely incidents.  So what changed, who allowed a relaxation, why; and, just who influenced that relaxation?"

Absolutely. There were NEVER so many incidents in the pre-LCC days. Back then only a qualified aircraft engineer headsetted an aircraft. Most were 'long in the tooth' Gingerbeers who were accompanied by long serving ground crew in the pushback tug, again many had decades of experience under their belt. It was simply the way it was! Now? Well now you don't even have an aircraft Engineer on the headset with some of our airlines, it could be an ex school teacher or pottery maker with less than a years airside experience doing the headset. And if it is a traditional pushback procedure with a tug and driver, well some of those lads again have a mere year or two ramp experience under their belt. Cost cutting, penny pinching and a total lack of understanding or appreciation of the process and safety risks by executive bean counters has seen the bottom of the barrel well and truly reached. 'Profits before safety'.

Nugget 2;
"Hood has a ‘get-out-of jail’ free card from the Senate – time to earn that trust. Start with ‘why’, suddenly we have a heap of “Light Contacts”. Mate! - there ain’t no such ducking thing: not when 150 + tons of fuel loaded machinery collide @ even 10 knots (5 each for the uninformed)"

The assessment and understanding of this incident by Hoody and/or his investigator through the comment of 'light contact' is again extremely worrying. Firstly, there is only ever 'contact'. Nothing should ever contact an aircraft in a manner it wasn't designed to do, EVER! And to label it 'light contact' is preposterous. Define 'light' Greg? What aircraft 'contact' scale do you measure against? Show us your matrix mate? Actually don't bother Greg, you speak utter bullshit. YOU have made an assumption based on no quantifiable measuring tool, and that is a dangerous precedent for any investigative authority to promote. An investigator investigates and reports using factual evidence, quantifiable analysis, not making up his own personal language or tools, FFS. Also, in the old days just having a set of mobile stairs rubber bumper touching the aircraft would see a pilot or ground engineer rip you a new one! But now, according to Hoody's boys; when you have two passenger aircraft and a wing from one collides with a tail cone of another and damages the shit out of the two aircraft causing a huge amount of damage it is just 'light contact'. UFB. Are these muppets serious?

Nugget 3;
"Get real – sort it out; or, alternatively - fuck off".

Good to see a no holes barred statement as above. Tom sums the ATsB situation up precisely. This level of incident and the subsequent investigation report is a disgrace. Greg, mate, if you can't do the job (and it certainly looks like you are following in Beakers footsteps), please expedite your exit from the building forthwith. In other words, fuck off, NOW.

The ATsB are obviously using the below methodology to determine what is a serious or non serious situation? Enjoy;

Perfect timing Ol'Tom, Gobbles & "K", look here at about 02:05...


Guess what Hoody if your 'key' responsibility is to pick up on 'safety trends' well your mob seem somewhat remiss in picking up on 'taxi rash' trends. Maybe your database desktop approach needs a few tweaks. After all if it took sixteen + years to discover an un-forecast WX related 'trend', which is still to be effectively risk mitigated. So one wonders how long will it take to risk mitigate the 'taxi rash' safety issue...


MTF...P2

Ps Hoody I reckon you need to ditch the suit in favour of the Toga...

---

RE: The search for investigative probity. - Peetwo - 12-16-2016

Dots to elephant prints & the joining of -  

On the BITN thread P9 drew attention to a UP thread dealing with Melbourne ATC procedures & aberrations:

Quote:Kharon wrote: [/url]There is on Pprune a particularly good thread running; it kicked off as polite inquiry to a perceived decrease in Melbourne ATC performance. It is heartening to see that the ATCO and pilots can hold a civilised discussion, exchange views and demonstrate grown up behaviour. The ATCO responses proving, yet again, how essential it is for pilots to understand the ‘system’ both parties are lumbered with. Bloody good thread. Worth the time.  

Toot toot.

Quote:Melbourne Air Traffic Control

---

What has happened to air traffic control in Melbourne? The performance has plummeted. You get a COBT (that system isn't particularly effective anyway) and then get holding. Some aircraft carry the required holding fuel and then have to divert as ATC gives them additional holding on top of that promulgated. The wind may be 150/10 and they are using one runway. The ATIS gives a ten knot tailwind (as do tower reports) but the tailwind isn't reflected on the TTF nor the windsocks. You get a delayed COBT by anywhere up to an hour then get track shortening and a high speed descent with the next closet aircraft ten miles ahead. The supposed congestion doesn't show on the TCAS nor on Flight Radar 24.

What is going on?

---

Originally Posted by Berealgetreal 

Couldn't agree more with the above.

I'm normally in the camp that defends ATC but I'm over Melbourne and I'm over both MEL and SYD incessant ATIS changes. Its to the point where its actually is a distraction and adversely affects safety. Thought about starting an identical thread many a time.

No doubt the COBT followed by LIZZI and ARBEY times and holding in CAVOK light winds is about staffing levels. Regardless, the Airlines pay top dollar for a cut price service and it seems to me that unless you are a pilot flying the line everyday then it doesn't matter. Everyday, every sector 365 days a year its the same story. COBT's have benefited Air Services and just added yet another item for pilots to deal with.

The ATIS changes [i]has to be legal ar$e covering, as a 2 knot wind change unless a tailwind makes absolutely no difference whatsoever apart from the other pilot putting there head down to write it on a card thats covered in changes.

Another favourite on descent "reduce speed to 210 kts" at about 5 miles to a limiting altitude without offering a height waiver. We're over it. And don't talk to us when we're on the rollout with a fistful of max landing weight with yet another tailwind on a wet runway.

Maybe its just me..[/i]

 
Keeping in mind that COBT stands for 'calculated off block time", let's see if in Hoody's new age of 'data trend monitoring', we can start joining some dots.  

(12-11-2016, 10:42 AM)Peetwo Wrote:  [url=http://auntypru.com/forum/-The-search-for-investigative-probity?pid=5968#pid5968]Hoody: "Pick a trend any trend??" -  

Perfect timing Ol'Tom, Gobbles & "K", look here at about 02:05...

Guess what Hoody if your 'key' responsibility is to pick up on 'safety trends' well your mob seem somewhat remiss in picking up on 'taxi rash' trends. Maybe your database desktop approach needs a few tweaks. After all if it took sixteen + years to discover an un-forecast WX related 'trend', which is still to be effectively risk mitigated. So one wonders how long will it take to risk mitigate the 'taxi rash' safety issue...

On the theme of 'causal chains' and 'trend lines', remember this...     

(11-02-2016, 07:06 AM)Peetwo Wrote:  Here we go again -

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

Background

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

(08-23-2016, 07:48 PM)Peetwo Wrote:  [quote pid='4286' dateline='1463186985']

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

Quote:Two serious Jetstar incidents under ATSB investigation

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

Yesterday:

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

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

• Summary
  

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

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

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

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

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

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

Destination: Sydney, NSW 
 


Last update 01 November 2016

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

Quote:DARREN CHESTER:

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



[/quote]

From my calculation there is at least three outstanding loading event aberrations for one airline that are currently on the ATSB investigation list and the question of when these investigations will be completed is anyone's guess...

However will wonders never cease because on reading the latest desktop SIB (short investigation bulletin), I was surprised to find that there had been another 'loading duck-up' incident from the same airline that had actually been investigated and completed in just over 3 months...

Quote:Final Report
Final Report
Download Final Report
[ Download PDF: 474KB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 1.83MB]
 
On 8 September 2016, at about 1900 Eastern Standard Time, an Airbus A320-232 aircraft, registered VH-VFN, was being loaded at Sydney Airport, New South Wales, to operate Jetstar flight JQ820 from Sydney to Brisbane, Queensland.

The leading hand assigned to loading the aircraft had received the deadload weight statement (DWS) for the cargo from the cargo terminal operator (CTO), and printed out a copy to refer to while loading the aircraft. The DWS listed three containers of freight and the CTO had previously delivered three containers to the loading bay from their facility.

The leading hand checked the containers with those listed on the DWS. Two of the three listed containers were correct, however, the third was listed on the DWS with number 4183 and a gross weight of 240 kg, while the container on the bay was number 1483, which was subsequently found to have had a gross weight of 900 kg.

The container card associated with, and attached to the container also had number 4183 on it. The leading hand assumed that the freight handler had inadvertently transposed the first two digits of the container number from 14 to 41, entered that onto the card and transferred the error onto the DWS. The leading hand therefore amended the card and the DWS with the actual number of the container (1483), and entered that container number onto the underfloor load advice (ULA) as it was loaded onto the aircraft.

At about 1915, the leading hand completed loading the aircraft and took the paperwork, including the DWS and ULA, to the flight deck. The captain sighted the amendments and the leading hand affirmed, as they believed at the time, that the weight was correct and the container number was now correct on the DWS and ULA. 

The aircraft departed on time at about 1925. The flight crew were not aware of the discrepancy during the flight and did not encounter any handling or control issues on take-off or receive any abnormal indications.

This incident highlights how being service oriented to increase efficiency can inadvertently bypass safety-related risk controls.

   
Now this is where IMO the dots become elephant footprints because this yet again totally inadequate report actually states in the findings...

"..The short turnaround time combined with this being the last flight to Brisbane that night, along with the assumption there was a transcription error, resulted in the leading hand not requesting a new deadload weight statement and container card, and loading the incorrect container on the aircraft..."

What's the chances if you ran that statement, as a point of comparison, over the other three J* loading incidents being investigated; the taxi rash incidents; and some of the YMML ATC aberrations and even possibly some of the min fuel cock-ups; you might find a trend line in the data so far collated...

Just saying -



MTF...P2

Ps > 2 years to 3 months? - Yeah right and elephants might fly...

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