The search for investigative probity. - Printable Version

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RE: The search for investigative probity. - Peetwo - 05-06-2017

(05-06-2017, 08:56 AM)kharon Wrote:  Tactful of toothless?

Hi Sidebar; welcome. We too are waiting (quite a long wait) for the Pel-Air report. It promises to be an ‘interesting’ study piece. My ‘tote’ board has a record number of entries and, the written forecast results are very ‘entertaining’. Top money is for release on or about ‘Budget’ day. We shall see. But today we have the ATR incident to consider.

The ATSB report, although a long time arriving, is better stuff. This is what we may expect from a ‘deep’ investigation with the manufacturer involved and confirmation from the UK supports the ATSB conclusions; however.  Do the SR’s make good sense? Are you prepared to by-pass the radical causes?

ATSB: “The pitch disconnect occurred while the crew were attempting to prevent the airspeed from exceeding the maximum permitted airspeed (VMO)”.

ATSB – “The ATSB recommends that EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.”

But what of the crew actions which had the aircraft at ‘red line’, the conflicted elevator inputs which created the disconnect of the elevator channels and subsequent damage, caused by operations outside the ‘certified’ design envelope? Why are these elements not examined, in detail, before questioning the ‘integrity’ of the manufacturer and the certifying agency?

Limitations and certification tests, must, if aircraft are to fly, have ‘limits’ and then a ‘buffer’ about those limits which can be ‘reasonably’ supported. Simplistically put, an egg is ‘designed’ and tested to withstand certain anticipated loads, if it is a government certified egg, then if will be required to withstand that load + a ‘reasonable %’ more. Used correctly, your egg will last, throw it a wall with no more than that % above ‘test’ all is well. Go past that limit and you have a clean up job to do. The point I’m trying to make is if an airframe is ‘thrown’ at a wall, above the limitations imposed, something will break. The ATR is a proven, might tough airframe; the fact that it failed to ‘break’ during the initial incident and continued operations for quite a while afterwards, speaks well for design and certification standards. What is not being addressed by the ATSB is ‘how’ the initial damage was done; and, what caused it. Why is this element being so carefully stepped around? ATR cannot continue to increase allowable limits to an infinite value, on ATSB say so. It is an aircraft, not the harbour bridge.

I did at one time do the research into the force required to ‘separate’ the control channels; can’t find it now, but it was a significant number i.e. you have to really mean it. One pulls  back, the other pushes forward, the clutch disengages and you have independent elevator controls. So, somehow, even accidentally, the conflicting crew ‘actions’ have managed to not only separate the control channels, but, through opposing forces, imposed a greater load on the airframe than certification design specifications.

There may well be a ‘design’ and ‘certification’ weakness; but provided the aircraft met the certification requirements, as specified, and has been proven to exceed those specification through ‘hard’ use, then is it fair to question the integrity of the aircraft – as presented?

Another troubling part of this ATSB report is the lack of FDR and CVR data. I, for one, would very much like to know exactly what occurred on the flight deck and see the exact data provided by the FDR. In particular, the pitch channel and speed data for the entire sector. I wouldn’t mind seeing the original written reports from both aircrew and engineering either.

Vitesse (not velocity) Maximum Operating. (Vmo). Maximum Operating limit speed. Red line…

FAA - The pilot should be aware of the symptoms that will be experienced in the particular airplane as the VMO or MMO is being approached. These may include:

• Nose-down tendency and need for back pressure or trim.

• Mild buffeting as airflow separation begins to occur after critical Mach speed.

• Activation of an over-speed warning or high speed envelope protection.

Personally, I can’t remember ever pushing an airframe to the ‘red line’ as a regular practice; often close, but not deliberately to, for several reasons; gas for Mum, speed for the kids and height for my own peace of mind is always in the flight bag. I digress.

When this incident occurred, there were some good post on the UP related (some rubbish as well) but for those who would like to take their thinking beyond the narrow confines of the ATSB report; start –HERE -.

Good, but incomplete, ATSB marked 4 out of a possible ten, which is much better than the usual 1 or 2 they struggle to win. Although the following, carefully read, is a typical, ATSB conflicted nonsense.

The ATSB recommends that EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.

To what limits? It already meets the prescribed and proven better, so, what's the point?

For analysis of the inflight situation, ATR has used the aerodynamic model that was developed during certification. Preliminary results for the jamming scenarios was provided. Those results showed that the inflight system response is also that of an underdamped oscillatory system. It also indicates that the magnitude of the system response is dependent upon the pilot input to the control column, and how quickly the flight crew respond to PUM activation. The system has margin for jams at the elevator. ATR are continuing the analysis of jams at the control column.

Again, how long is a piece of string? Is it a King Kong v Faye Wray tussle or two average pilots pulling and shoving? Balanced, I don't think so.

The ATSB acknowledges the efforts of ATR to resolve the safety issue. The ATSB also notes that, while the short term risk assessment does not account for the transient elevator deflections associated with a pitch disconnect, until the results of the detailed engineering analysis are available it is not possible to accurately quantify the transient elevator loads. Consequently, it is not possible to fully determine the magnitude of the risk associated with continued operation of ATR42/72 aircraft until the engineering analysis is complete.

Noting the above, the ATSB’s retains a level of ongoing concern as to whether the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. Consequently, while the ATSB accepts that the current level of safety action partially addresses the safety issue; the ATSB makes the following safety recommendations.

Somebody, anybody, please: explain what that last load of double speak bollocks means.

 
Toot – sigh – toot.

Recent media coverage on ATSB ATR 2nd interim report.

Via FlightGlobal:

Quote:ATSB airs safety concerns on ATR pitch controls

• 05 May, 2017
  
• SOURCE: Flightglobal Pro
  
• BY: Ellis Taylor
  
• Perth
  

The Australian Transport Safety Bureau (ATSB) has called on ATR to quickly complete an engineering assessment of the type's pitch control system, amid possible concerns that a serious design flaw may be present in the ATR 42 and 72 series.

The recommendation was made in the Bureau's second interim report into a 2014 incident in which the crew of a Virgin Australia ATR 72-600 (VH-FVR) made strong opposite inputs to the pitch controls, leading to a 'pitch disconnect', which uncoupled the left and right controls to the elevators.

This resulted in potentially catastrophic damage to the aircraft's horizontal stabiliser, while a cabin crew member was seriously injured by the aerodynamic loads generated during the event. However, the damage was not detected for five days, after which the aircraft was grounded for several months before returning to service.

In the earlier phases of its investigation, the ATSB identified that "transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads that could exceed the strength of the aircraft structure."

An interim report released by the Bureau in June 2016 identified that the opposite control inputs were "not part of normal procedures", but added that "the existing procedural risk controls alone may not be sufficient to prevent this type of occurrence".

The ATSB's second report follows greater analysis of ATR's design for the pitch control mechanisms and their performance during a pitch disconnect event.

It found that flexibility within the pitch control system cables led to a rebalancing of loads in the system following the activation of the pitch uncoupling mechanism, and "dynamic transient elevator deflections" shortly after the mechanism was activated.

It also found that there was "unavoidable movement of the control column(s)" after the mechanism had been activated.

"Each of these effects may contribute to elevator deflections greater than the aircraft manufacturer considered during the design and certification of the aircraft," the ATSB adds.

In December, ATR undertook an assessment of the short term risks with the system. This concluded that the system was safe as the ultimate loads could not be exceeded through the control column, and that the probability of a similar event happening was low.

Nonetheless, in January FlightGlobal reported that ATR planned to update the operating manuals of its aircraft to warn pilots of the risks involved in making large flight control inputs.

The manufacturer is also undertaking a detailed engineering analysis using an analytical model backed up by ground and flight testing. Further modelling of dual input scenarios and flight testing is being carried out, in association with the European Aviation Safety Agency (EASA), which is the certifying authority for the aircraft.

"In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft," the report says.

The ATSB has also called on EASA to monitor and review the engineering analysis to determine if the aircraft can withstand loads resulting from a pitch disconnect. 

"In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft," it adds.

Via Asiacruise news:

Quote:Threat To ATR Turboprops Concerns Australian Investigators.




05 May 2017
Safety recommendations issued to manufacturer and regulators as a result of investigation into serious Virgin Australia incident.
>
ATSB images showing damage to the ATR72's tail.

Australian air safety investigators are worried a repeat of a damaging incident that crippled a Virgin Australia ATR72 turboprop in 2014 could lead to another aircraft suffering significant structural damage.

 The February 20, 2014, incident occurred when two flight crew attempting to slow the ATR 72 aircraft during descent into Sydney inadvertently applied opposing control inputs and triggered a “pitch disconnect’’. This resulted in serious damage to the aircraft’s tail and injured a senior cabin crew member.

However, the plane was initially thought to have experienced “moderate turbulence’’ and flew for several days, despite a visual inspection by an engineer, before the severe damage to the tail was detected and it was grounded on February 25.

Pitch is controlled by pilots pushing and pulling on the control column to lower or raise the aircraft’s nose. By moving the horizontal panels on the aircraft’s tail, or elevators.

The elevators normally move in the same direction and in equal amounts but there is a mechanism, the pitch uncoupling mechanism, which allows them to operate independently in the event one jams.

By pushing the control columns in opposite directions, the Virgin pilots activated this mechanism and subjected the aircraft to stresses it was not designed to take.

Australian Transport Safety Bureau continued to investigate the incident and discovered there are momentary elevator deflections during a pitch disconnect that could lead to aerodynamic loads capable of exceeding the design strength of the aircraft.

They also discovered these transient elevator deflections had not been identified when the aircraft type was originally certified.

The ATSB was sufficiently concerned about the potential impact to put out a second interim report making three recommendations.

It has asked ATR to complete an assessment of the safety issue as soon as possible to determine whether the aircraft can safely withstand those loads.

It has also asked the European regulator, EASA, and the Australia’s Civil Aviation Safety Authority to review ATR’s engineering assessment “and take immediate action if the analysis the aircraft does not have sufficient strength’’.

 “Our concern is that, given the design of the ATR42 and ATR72 aircraft, opposing control inputs can result in aerodynamic loads that may exceed the design strength of the tail structure, causing significant damage," ATSB chief commissioner Greg Hood said.

"Since we identified this issue, our aeronautical and structural engineers have conducted extensive analysis based on additional data provided by ATR. The findings of that analysis, supported by an independent peer review from the UK Air Accidents Investigation Branch, confirmed our initial concerns."

ATR is continuing to conduct further engineering analysis of the issues raised by the ATSB and Australian operators of ATRs, Toll Aviation and Virgin Australia, have taken action to minimise the chances of the situation reoccurring and to train pilots to manage it if it does.

Virgin said Friday it was confident the risk mitigation procedures it had introduced meant the aircraft remained suitable for operations.

“Safety is Virgin Australia’s number one priority, and we continue to liaise closely with the relevant regulatory bodies and the aircraft manufacturer in relation to the Australian Transport Safety Bureau’s ongoing investigation into the ATR’s pitch disconnect mechanism,’’ it said in statement emailed to AirlineRatings.

EASA’s initial response was to issue a safety information bulletin which said it did not consider the problem an unsafe condition that would warrant an Airworthiness Directive.
CASA said it was closely monitoring the ATSB investigation.

“CASA continues to audit ATR aircraft operators to ensure appropriate actions have been taken to reduce the likelihood of the aircraft being mishandled in a manner similar to the incident flight,’’ it said. 

“Flight procedures and pilot refresher training for the ATR aircraft operated in Australia have been amended since the event occurred.

 “CASA will look carefully at the findings of the aircraft manufacturer’s engineering analysis of the issues associated with a pitch disconnect when this work is completed.

 “If this analysis raises any ongoing safety issues CASA will take appropriate action.  CASA will take into account any measures taken by EASA. ‘’

ATR said: "In conjunction with EASA, ATR is completing the assessment of transient elevator deflections. Via the BEA, ATR continues to provide assistance to the safety investigation conducted by the ATSB."

The investigation into the Virgin incident is continuing.

Source : http://www.airlineratings.com/news.php?id=1214

MTF...P2

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RE: The search for investigative probity. - Kharon - 05-08-2017

Point of order Mr. Chairman.

"The elevators normally move in the same direction and in equal amounts but there is a mechanism, the pitch uncoupling mechanism, which allows them to operate independently in the event one jams."

"By pushing the control columns in opposite directions, the Virgin pilots activated this mechanism and subjected the aircraft to stresses it was not designed to take."

This whole ATSB, CASA and ATR dialogue omits one essential element. The aircraft did not have a ‘control jam’. There was no cool headed decision made to ‘disengage’ the elevator channels and no requirement to do so. There was also no ‘auto pilot’ fault flagged. So, how did the ‘disconnect’ event which led to the aircraft being damaged occur? Was the AP actually fully disengaged before 'strong' manual input? Why did one crew member think pull ‘up’  was the cure and the other believe ‘push’ down a solution? Seems to me there are there serious questions which need to be answered before batting the ball back to ATR. There may well be other incidents where the crew became confused and inadvertently disconnected the elevator channels – but I’m blessed if I can find them. There are a couple of incidents where this has been deliberately done – without damage to the airframe. Perhaps there is a much simpler, untested, line if inquiry close to home. Seems to me the obvious  questions should be eliminated first, before this esoteric discussion on the black art of test flying and certification is entered into – at great expense

If it walks like a duck - just saying..

Toot toot.

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RE: The search for investigative probity. - Peetwo - 05-08-2017

(05-08-2017, 07:04 AM)kharon Wrote:  Point of order Mr. Chairman.

"The elevators normally move in the same direction and in equal amounts but there is a mechanism, the pitch uncoupling mechanism, which allows them to operate independently in the event one jams."

"By pushing the control columns in opposite directions, the Virgin pilots activated this mechanism and subjected the aircraft to stresses it was not designed to take."

This whole ATSB, CASA and ATR dialogue omits one essential element. The aircraft did not have a ‘control jam’. There was no cool headed decision made to ‘disengage’ the elevator channels and no requirement to do so. There was also no ‘auto pilot’ fault flagged. So, how did the ‘disconnect’ event which led to the aircraft being damaged occur? Was the AP actually fully disengaged before 'strong' manual input? Why did one crew member think pull ‘up’  was the cure and the other believe ‘push’ down a solution? Seems to me there are there serious questions which need to be answered before batting the ball back to ATR. There may well be other incidents where the crew became confused and inadvertently disconnected the elevator channels – but I’m blessed if I can find them. There are a couple of incidents where this has been deliberately done – without damage to the airframe. Perhaps there is a much simpler, untested, line if inquiry close to home. Seems to me the obvious  questions should be eliminated first, before this esoteric discussion on the black art of test flying and certification is entered into – at great expense

If it walks like a duck - just saying..

Toot toot.

Update: PT & Discus.

Excellent deliberations "K" to which I totally agree...

As "K" points out the whole idea of having a pitch disconnect system is to have a back-up in the unlikely event of a pitch control jam. Such a situation calls for a conscious decision and deliberate actions by the flight crew - something that obviously did not occur in this incident. Therefore, how can the ATSB seriously be calling for what basically amounts to a re-certification process, for a tried and true airframe (in service since 1989 for the -72 and 1984 for the -42); when seemingly the other (now extremely mouldy) Swiss cheese holes have not been thoroughly investigated and/or explained? 

Spot the disconnections?  

Quoting ATSB high viz spokesperson Greg Hood:

Quote:"The ATSB released its first interim report into this incident in July last year. That report identified a significant safety issue relating to the strength of the aircraft's tail structure in the event of a pitch disconnect," Mr Hood says.

"Our concern is that, given the design of the ATR42 and ATR72 aircraft, opposing control inputs can result in aerodynamic loads that may exceed the design strength of the tail structure, causing significant damage."

"Since we identified this issue, our aeronautical and structural engineers have conducted extensive analysis based on additional data provided by ATR. The findings of that analysis, supported by an independent peer review from the UK Air Accidents Investigation Branch, confirmed our initial concerns."

"The ATSB welcomes the engagement with the European and Australian regulators EASA and CASA, and the safety action taken by the manufacturer ATR, who continues to conduct further engineering analysis of the issues identified by the ATSB."

And from the PT article...

Quote:
ATSB sounds alarm about certification blind spot in ATR turbo-prop
Ben Sandilands 5, 2017 16 Comments
More safety issues with the infamous Virgin Australia ATR 72 incidents of 2014 have emerged

..on the ATSB 2nd interim report and to further highlight this (again) bizarre BASR ATSB disconnect, I refer to an excellent rational & Reasoned Discus comment (note parts in red bold)..  :

Quote:Discus
May 6, 2017 at 1:59 pm

It appears that the manufacturer had not identified the risks of uncoupling with both control columns free to move asymmetrically, or that the force required to uncouple would mean that there would be sudden, unavoidable movement in whichever direction a crew member was pushing , pulling or both at the same time, as it was in this case. That is serious if found to completely factual as it derails everything thereafter.

This being the case, it is likely that the requirements of the inspection in accordance with the aircraft maintenance manual did not involve mandatory removal of the fairings that would cover the vast majority of, if not all of that obvious damage.

Without pre-empting the investigation’s findings, it seems that there were some problems in the cockpit . Having one pushing, one pulling to avoid an over speed sounds like very poor flying to me. The subsequent write up for engineering is crucial as to what inspections and checks are mandated.

Given the manufacturer had not identified the possible problem, the engineers may have done everything in accordance with the manuals for what was reported. As an engineer myself and worked in line maintenance for about 30 years, we need to rely on what is reported as being accurate. We are not allowed to deviate from what the manuals tell us. If moderate turbulence is reported and that situation only requires a “General Visual Inspection (GVI)” that is exactly what is done. You lose jobs and or contracts for grounding aircraft and doing inspections etc that are not required by the manufacturer’s manuals for any given report from the flight crew.

In Ben’s previous post https://blogs.crikey.com.au/planetalking/2014/06/10/virgin-australia-flew-13-passenger-flights-in-broken-turbo-prop/ on this incident, it was noted in the comments that the flight crew may not have initially report the turbulence, just the disconnect and it was upon the suggestion of the engineer to write the turbulence up and iirc it was described as “moderate”. In this case it seems a “general Visual Inspection” was required. A GVI really is a walk around.

Boeing for example describes a GVI as done from the ground without special stands or equipment.

Now, if there was obvious damage that was missed the signing engineer , he or she may have serious problems, but if that damage is covered by fairings that are not required to be removed during the required inspection and that inspection was carried out diligently, in accordance with the documentation, that engineer is within their rights to sign off on it.

As usual, there is a sequence of events , lining up the holes in the Swiss cheese, that allowed this to happen starting with the manufacturer , then the crew’s actions whilst flying, possibly their report to engineering and perhaps the engineers.

Careful Discus we all know how sensitive Hoody is when it comes to critiquing and questioning the ATSB BASR approach to AAI - remember this from Hoody's correcting the bollocks page? (reference: Hoodlum gets defensive)

Quote:Inaccuracies in reporting of an ATSB investigation In-flight pitch disconnect involving an ATR 72 aircraft

14 July 2016

The article by Martin Aubury, ‘Luck stops an air disaster waiting to happen’, published in several Fairfax publications on 11 July 2016 contains factual errors and misunderstandings. In the interests of ensuring truth and transparency, the ATSB considers it necessary to correct the record. In the article, Mr Aubury cites the ATSB’s on-going investigation into an in-flight pitch disconnect involving a Virgin Australia Regional Airlines (VARA) ATR 72 aircraft while descending into Sydney, NSW on 20 February 2014.

Mr Aubury claims that it took the ATSB several years to publicly report its investigation into the incident. In fact, the ATSB published an initial web update on its investigation on 10 June 2014. A second, interim report was published on the ATSB’s web site on 15 June 2016.

Mr Aubury’s article also claims the ATSB’s interim report ‘understates the seriousness of what went wrong’ and says little about why the damage to the aircraft was not found on the ground for five days.

The ATSB’s investigation into this incident is still ongoing. As discussed in the interim report, the ATSB’s investigation activities to date have included the collection and analysis of maintenance documentation and procedures of the operator and the maintenance organisation. ATSB is also examining the Civil Aviation Safety Authority’s surveillance and approvals involving the operator and maintenance organisation. ATSB is further involved in on-going enquiries and discussions with the aircraft manufacturer in France (ATR), the safety investigation agency in France (BEA), and the European regulatory authority (EASA). ATSB is further involved in on-going dialogue with neighbouring States who have operators utilising the ATR42 and ATR72 aircraft.

The ATSB’s interim report was intended to provide factual information and analysis associated with the identified safety issue. That safety issue highlighted the risk of inadvertent and opposing activation by flight crew of the aircraft’s elevator control system in certain high-energy situations.

The ATSB’s final report (expected to be released in December this year) will provide a comprehensive analysis and findings of all areas investigated, including into maintenance issues.
 
This is a complicated investigation with several areas requiring thorough analysis.
The ATSB is disappointed that this article was published without the author seeking comment, amplification, explanation nor clarification from the ATSB in relation to this investigation.
 

 To which Martin Aubury responded: OZAUB defends his honour

Quote:On 11 July Fairfax Media published my account of the Virgin ATR 72 debacle at Plane lucky: an aviation escape. ATSB took umbrage and published a rebuttal on 14 July at https://www.atsb.gov.au/newsroom/correcting-the-record/. I stand by my article and deny it “contains factual errors and misunderstandings”.


Since ATSB is so defensive of its lengthy investigation let’s spell out the timeline and compare it with Indonesia’s investigation of the AirAsia QZ8501 accident.

On 20 February 2014 the pilots of a Virgin ATR 72 mis-handled control inputs and overloaded the tailplane by 47 percent beyond ultimate design capability. Nowadays we design aircraft precisely, with no extra strength “for Mum and the kids”. So it is pure luck that the structure held together. For the next 5 days nobody noticed serious damage and a visibly twisted tailplane. The critically weakened airliner stayed in service and carried hundreds of passengers until the damage was found largely by luck.

On 10 June 2014 ATSB published an interim report of the accident, which described the damage but not its cause or why the damage went unnoticed.

On 15 June 2016 ATSB published a second interim report which quantified the overload, explained its cause and alerted operators that inadvertent application of opposing pitch control inputs can catastrophically damage ATR 72 and ATR 42 aircraft. ATSB seems not to have warned operators of other aircraft with similar controls. And 28 months after the accident ATSB is still analysing why post-occurrence inspections failed to detect such gross damage.

Meanwhile on 28 December 2014 an AirAsia Airbus A320 crashed after a series of mistakes culminating in somewhat similar control mis-handling by the pilots. It took Indonesian investigators just 12 months to recover wreckage, extract flight data, analyse a complicated accident scenario and publish a thorough analysis of what went wrong.

ATSB must explain why its investigation is taking so long, and Virgin and CASA must be held to account for why so many passengers were put in jeopardy. Otherwise Australia’s aviation luck may run out.

So after 1174 days since this accident first occurred and 328 days since the ATSB 1st publicly identified these safety issues, the Martin Aubury 'please explain' comment is yet to be addressed and the ATSB investigation is yet to see action that effectively mitigates these safety risks...

Once again IMO it is questionable whether the ATSB has become part of the accident causal chain...


MTF...P2

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RE: The search for investigative probity. - Kharon - 05-08-2017

Discusted or Digusted

Hood should resign; this ain’t getting any better

Discus. “It appears that the manufacturer had not identified the risks of uncoupling with both control columns free to move asymmetrically, or that the force required to uncouple would mean that there would be sudden, unavoidable movement in whichever direction a crew member was pushing , pulling or both at the same time, as it was in this case.”

Whoa, hold it right there.  Why would you ‘consider’ risks associated with ‘asymmetrically’ opposed control channel input? The system exists for one purpose only – to provide a single channel of control movement - when, and only when the other bloody channel has ‘jammed’; and certainly not a chance to practice arm-wrestling. What happened to rule 101 of ‘multi crew’ operations – who has control. “My controls” – “handing over”. How may thousands of times a day is that phrase used; why? Well it’s so there is no confusion about who is doing what -  particularly if the other chap can’t do it anyway because his ducking controls are ‘jammed’ – Cheeses stinks to high heaven.  Who would consider that ‘professional’ aircrew could end up in such a pickle, two pair of hands on the yoke - bullshit; or,  that the disagreement in their control input would create a control channel disconnect. This is not an aircraft for amateurs; the airline is not a flight school; these were, supposedly, competently trained, tested and checked professional airmen. So, I reiterate; WTF was happening on that flight deck? What was the aircraft configuration, speed and RoD? Where are the CVR and FDR reports. Was the AP on; off; or ‘soft’?  

Three years to get half the job done and then ATSB try to parlay it into a, perhaps, maybe, ‘design fault’. Just who’s ‘design engineers’ support that claim – not ATSB’s; they ain’t got any. Not that ATR would take the discredited ATSB too seriously anyway; three years to say ‘we think you have a design problem – Bollocks. The French will  probably present the ATSB with a very Gallic, richly deserved ‘taunting’.

Thus, suitably lubricated, for your entertainment:- Vive la France....

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RE: The search for investigative probity. - Gobbledock - 05-08-2017

P2;

Once again IMO it is questionable whether the ATSB has become part of the accident causal chain...

And once again while this relatively uncomplicated investigation drags on for years the actual 'risks' remain a serious issue. Until the correct root cause has been identified and mitigation achieved the risk remains active. Is it a structural issue? Is it an engineering procedure (or lack of)? Is it pilot error - fatigue, training, incompetence? Notice I say 'is' not 'was', because until the incident is solved it remains 'is' as the risk of reoccurrence is still out there. Therefor, as P2 astutely points out, the ATsB itself could be contributing to an ongoing aviation risk.

Maybe Herr Thor, ICAO's 'font of knowledge' can use that big hammer of his to smash through the layers of hardened bullshit that has covered the ATsB and become fossilised?

P.S I can definitely sense a Hoody 'correct the record' coming on! Hoody, take your 'corrected records' and shove them up your ass.

Tick 'effing' Tock

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RE: The search for investigative probity. - Kharon - 05-09-2017

(05-08-2017, 09:38 PM)kharon Wrote:  Discustard or Digusted

Hood should resign; this ain’t getting any better

Discus. “It appears that the manufacturer had not identified the risks of uncoupling with both control columns free to move asymmetrically, or that the force required to uncouple would mean that there would be sudden, unavoidable movement in whichever direction a crew member was pushing , pulling or both at the same time, as it was in this case.”

Whoa, hold it right there.  Why would you ‘consider’ risks associated with ‘asymmetrically’ opposed control channel input? The system exists for one purpose only – to provide a single channel of control movement - when, and only when the other bloody channel has ‘jammed’; and certainly not a chance to practice arm-wrestling. What happened to rule 101 of ‘multi crew’ operations – who has control. “My controls” – “handing over”. How may thousands of times a day is that phrase used; why? Well it’s so there is no confusion about who is doing what -  particularly if the other chap can’t do it anyway because his ducking controls are ‘jammed’ – Cheeses stinks to high heaven.  Who would consider that ‘professional’ aircrew could end up in such a pickle, two pair of hands on the yoke - bullshit; or,  that the disagreement in their control input would create a control channel disconnect. This is not an aircraft for amateurs; the airline is not a flight school; these were, supposedly, competently trained, tested and checked professional airmen. So, I reiterate; WTF was happening on that flight deck? What was the aircraft configuration, speed and RoD? Where are the CVR and FDR reports. Was the AP on; off; or ‘soft’?  

Three years to get half the job done and then ATSB try to parlay it into a, perhaps, maybe,  ‘design fault’. Just who’s ‘design engineers’ support that claim – not ATSB’s; they ain’t got any. Not that ATR would take the discredited ATSB too seriously anyway; three years to say ‘we think you have a design problem – Bollocks. The French will  probably present the ATSB with a very Gallic, richly deserved ‘taunting’.

Thus, suitably lubricated, for your entertainment:- Vive la France....

Addendum: - sorry I can’t get the NTSB ‘link’ (below) to work – perhaps P2 can? But I did find a BEA briefing which, IMO, demonstrates what real AAI do and make a contribution to ‘closing the loop’, rather than potentially allowing what should be preventable accidents reoccurring.
 
FWIW, the NTSB investigation of the incident below took – not too long – and, closed one hangman's loop before it could snare another aircraft. Potential; repeat avoided. Flight crew did it well, by the book and very nicely.
 
An American Eagle Aerospatiale ATR-72-500, registration N494AE performing flight MQ-4756 from Midland,TX to Dallas Ft. Worth,TX (USA) with 41 passengers and 4 crew, was in level flight with the autopilot engaged, when the crew noticed a pitch mistrim message, disconnected the autopilot and found both control columns restricted in their fore and aft movements with a maximum movement of about one inch foreward and one inch backward. The crew attempted the jammed elevator checklist procedure twice, but was unable to uncouple the elevators (break the link between the two control columns). After slowing to 180 KIAS the crew found better control of the elevator. When the airplane lined up for the final approach, the elevator again seemed to have jammed. The crew went around and conducted a second, shallow approach to a safe touch down. While taxiing to the gate the elevators became unjammed and the crew regained full control of the elevators.

The NTSB released their preliminary report stating, that maintenance personnel found the brackets holding the left hand elevator down limit stop had fractured and separated from the elevator, so that the down limit stop restricted the movement of the left hand elevator.

The cockpit voice and flight data recorder were secured, several damaged parts in the area of the left hand stabilizer area and the left elevator were removed for further investigation. The NTSB concluded: "The rest of the airplane was released to the operator."

Even a touch of humour thrown in with the report, not a hi-viz vest in sight. Real safety, in real time - at work. Bravo NTSB.

Toot - toot..

---

RE: The search for investigative probity. - Peetwo - 05-19-2017

Hoody's (growing) COI list taints ATCB search for IP -

Reference post on Hoody's conflicted CV... : The Iron Ring strikes back

Quote:Mr Hood: The accident occurred when I was involved in regulatory oversight with the Civil Aviation Safety Authority. Prior to my appointment as the chief commissioner of the ATSB, I declared to the minister and to the ATSB commission a potential or perceived conflict of interest in relation to my involvement and approval in that report. With that in mind, the proposal I put forward to the minister and to the commission is that Captain Chris Manning would be the commissioner who would be responsible for the ongoing approval of and release of that report. As a result of this committee and the ASRR, the Aviation Safety Regulation Review, which recommended the appointment of an aviation commissioner, Captain Manning is the first aviation commissioner of the ATSB. He is a former chief pilot at Qantas and the former president of the Australian and International Pilots Association. So he is very well-qualified in this area. With respect to my conflict of interest—or perceived or potential—Captain Chris Manning and the other aspect are being cared for by Pat Hornby, who is the manager of our legal services, so for any questions I will defer to those two...

Given the bizarre, micro-managing, high viz performance since that time, I now firmly believe that Hood was hired as Murky's 'Mandarin pick' as the perfect foil and Beaker replacement, for the continuing PelAir cover-up reinvestigation and indeed the MH370 SIO search cock-up and/or cover-up.

Like Beaker was most definitely the patsy to the Lord Sith of the Iron Ring, so to is there much evidence that Hoody is re-incarnated as the next voodoo Muppet to Dr A...

Here is another example of a perceived Hood 'COI' that could create further questions of ATCB independence and investigative probity. Remember this? 

(02-23-2016, 05:58 PM)Peetwo Wrote:  CASR 175 certification?

Apparently in a quiet moment less than a week ago, after a year of transition, the CASA AAD officially rubberstamped...err certified ASA under CASR 175.

Strangely this was done with little to no fanfare and with only a Hoody & Cromarty handshake happy snap taken for posterity:


Maybe it is just me but I would have thought this was a proud moment in the history of ASA..

I also find it 'passing strange' that Cromarty did not mention, while under questioning from the Senators at Estimates, that the AAD had (presumably) recently audited ASA in preparation for the rubberstamping of the CASR 175 certificate..   If he had of done that it may have allayed some of the Senator X recent lack of oversight concerns by CASA of ASA:

From the Senate Estimates it would also appear that everyone - ASA, CASA, Dick Smith & the Senators - except for the ATSB totally missed the incident reported in the Senate Estimates thread today:

(02-23-2016, 11:40 AM)Peetwo Wrote:  

(02-23-2016, 11:09 AM)Peetwo Wrote:  From off the 'bump in the night' thread post #269

Quote:"..Compared with other countries, in Australia you are almost in complete silence all the time. I have said to the air traffic controllers, 'But couldn't you do a little bit more of a workload and actually give us an air traffic control service where we need it?' And quite a few of the controllers have said to me, 'Well, of course we can, but don't tell anyone I told you that'! I fly to Ballina from time to time, and you get this superb service from Bankstown's air traffic control; you just do what you are told. You get told to taxi out to the runway, and you ask for a clearance for take-off, and you take off, and the controller says 'Turn right to 120 degrees', and you meet the airway, and he or she says 'Turn left' and you follow the airway under air traffic control. The most amazing thing is that as you get to 8½ thousand feet, that is the only place on the whole trip where you can actually run into somebody. Up at 45,000 feet the airways are separated, going towards Brisbane and to the right by about 10 miles, from the one coming the other way, and up at 45,000 feet where I fly it is very unlikely for anyone to be there anyway. But when you actually get down to below 8½ thousand feet, the statistics show that is where the mid-air collisions can happen and it is where you can run into a mountain. I then get told, as the pilot—and I am a single pilot when I fly the plane; I do not have a copilot to start writing down call signs—'Traffic is'. In the worst situation, I was given four other aircraft, because the Lismore approach happens to be mingled up with the approach to Ballina. I write down on my pad, 'Four planes', and then I change off onto the aerodrome frequency and I start calling these planes and trying to sort out where they are.

To an Aussie pilot, that is just normal; that is the way we do it. But if you are a pilot from another country you simply cannot believe that a leading aviation country in the world can have something that is so archaic. If we brought in some class E airspace, as planned 20 years ago, instead of the en route controller—it is not an additional controller—giving you traffic information on three or four aircraft the controller would look at his or her radar screen down to about 3,000 feet and below the radar screen they would look at their flight strips on the electronic display, and they would separate you. It is called procedural separation. They would say, 'Hold at 6,000 feet' or 'Do the approach', and they would say, 'I'm holding an aircraft on the ground to depart.'

What I find incredible is that after 20 years we have not gotten even one airport in. And I have said to people who are against it—because resistance to change is staggering—'Let's just try one; if it is going to require hundreds of extra controllers then we obviously cannot afford it.' But my advice is that it will not. To the pilots who say they do not need it I say that I think after flying in it for three or four months you will find that it is a fantastic system.."

  

Okay now reflect on the summary from ATSB investigation AO-2016-003:

Quote:In preparation for departure from Ballina/Byron Gateway Airport, New South Wales the crew of Airbus A320, registered VH-VQS, was in radio contact with the crew of two arriving aircraft. After establishing the intentions of the arriving aircraft, VH-VQS entered the runway and lined up. While holding prior to take-off, the crew of VH-VQS clarified their plan for maintaining altitude separation with the crew of one of the arriving aircraft. This delayed the departure of VH-VQS and resulted in the second arriving aircraft being closer to VH-VQS than anticipated as it commenced take-off. During the initial climb out, the crew of VH-VQS realised the second aircraft was closer than anticipated and reduced the rate of climb in response. After re-establishing the separation plan, the crew recommenced the climb and departed.

The investigation is continuing.

This incident may turn out to be a storm in a teacup, however the fact that the ATSB is actually investigating would seem to indicate there is a little more to it than the summary suggests??

 

Keeping the above in mind, today I note that the ATSB investigation AO-2016-003 final report has ( yawn) finally been released:

Quote:What happened

On 14 January 2016, whilst taking-off from Ballina/Byron Gateway Airport, Airbus A320, registered VH-VQS (VQS) and operated by Jetstar Airways, came in close proximity to Beech Aircraft Corporation BE-76 Duchess, registered VH‑EWL (EWL). The Duchess was conducting navigation training in the vicinity of the runway and was noticed by the flight crew of VQS during the take‑off roll and below the maximum speed from which they could stop.

The take-off was continued and while manoeuvring to maintain separation from EWL, the crew of VQS received master warning/caution alerts regarding the aircraft’s configuration. The crew also commenced flap retraction at low altitude and turned contrary to operator-prescribed departure procedures before departing for Melbourne. There were no injuries or damage to equipment recorded during the occurrence.

What the ATSB found

The ATSB found that despite an increase in passenger numbers and a mixture of traffic, Ballina/Byron Gateway Airport operated without the support of air traffic information and/or services. While recognising that a direct comparison between airports is difficult, Ballina also experienced a higher number of incidents relating to communication and separation issues compared to airports with similar traffic levels. The ATSB also found that a number of non‑standard operating practices and procedures led to a breakdown of crew resource management and the ability to adequately manage the dynamic situation by the crew of VQS. Finally, the ATSB found that the level of communication between the crews of VQS and EWL was inadequate to develop a shared mental model of what each crew was intending to do to ensure separation.

What's been done as a result

Following a recommendation by the Civil Aviation Safety Authority (CASA), the operator of Ballina/Byron Gateway Airport implemented a certified air/ground radio service (CA/GRS) to provide weather services and traffic information at the airport. This service commenced in March 2017 and operates daily between 0800 and 1800 local time. The CASA Office of Airspace Regulation is planning a post‑CA/GRS implementation review in mid-2017 to assess its effectiveness.

Additionally, Jetstar Airways have proposed to increase their annual audit schedule of common traffic advisory frequency operations, reviewed their jump seat policy when operating in such aerodromes to assist in distraction management, and altered their training matrix to further include exercises pertaining to levels of assertion and upwards managing by first officers.

Safety message
Operations at non‑controlled airports remain a safety watch priority for the ATSB. This occurrence highlights that traffic separation in that environment relies on a clear and shared plan between involved aircraft.

Adherence to standard operating practices and procedures promotes a shared understanding of crew’s actions by making them ordered and predictable to the other pilots. As well as reducing the likelihood of task omission or duplication during times of high workload, standardised practices and procedures decrease the mental demand on flight crew when carrying out a set of complex steps, allowing for better processing of unexpected events.

---

Findings


From the evidence available, the following findings are made with respect to the traffic management occurrence involving Airbus A320, registered VH-VQS and operated by Jetstar Airways, and a Beech Aircraft Corporation Duchess BE-76, registered VH-EWL that occurred at Ballina/Byron Gateway Airport, New South Wales on 14 January 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area. [Safety Issue]
  
• In addition to conducting the pilot flying role, the captain of VH-VQS assumed control of the radio to ensure separation with the incoming aircraft VH-VUE. This increased the captain's workload, resulting in reduced positional awareness of the more proximal VH-EWL and a subsequent traffic conflict with that aircraft.
  

Other factors that increased risk

• The non-adherence to standard operating procedures by the captain of VH-VQS, although possibly influenced by a desire to expedite the take-off, was consistent with a steep cockpit authority gradient. This resulted in a lack of crew shared understanding and distraction, removing the opportunity for the first officer to identify the impending traffic conflict.
  
• Despite a positive separation plan between VH-VUE and the two other aircraft, no such plan was established between the pilots of VH-EWL and the crew of VH-VQS. This led to the pilots of VH-EWL expecting VH-VQS to remain in the line-up position until after VH-EWL had completed the missed approach and therefore not perceived as a conflict threat.
  
• The radio call to inform Ballina/Byron Gateway traffic that VH-VQS was rolling was transmitted after the take-off roll had commenced. This limited the opportunity for the instructor in VH-EWL to process the situation and ensure adequate separation.
  
• The decision by the crew of VH-VQS to remain below VH‑EWL’s operating altitude after take‑off, although intended to assure adequate separation until sufficient lateral separation was established, resulted in non‑standard handling of the aircraft and the activation of a number of master warning/caution alert
  

Safety issues and actions

The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Air traffic facilities at Ballina/Byron Gateway Airport

Safety Issue: AO-2016-003-SI-01
Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.

  
So did Hoody declare himself possibly conflicted with this investigation as well?? And remembering that he was also involved with the Mildura Fog duckup investigation - so where does it stop??

 

MTF...P2

---

RE: The search for investigative probity. - Peetwo - 05-20-2017

(05-19-2017, 01:21 PM)Peetwo Wrote:  Hoody's (growing) COI list taints ATCB search for IP -

Reference post on Hoody's conflicted CV... : The Iron Ring strikes back

Quote:Mr Hood: The accident occurred when I was involved in regulatory oversight with the Civil Aviation Safety Authority. Prior to my appointment as the chief commissioner of the ATSB, I declared to the minister and to the ATSB commission a potential or perceived conflict of interest in relation to my involvement and approval in that report. With that in mind, the proposal I put forward to the minister and to the commission is that Captain Chris Manning would be the commissioner who would be responsible for the ongoing approval of and release of that report. As a result of this committee and the ASRR, the Aviation Safety Regulation Review, which recommended the appointment of an aviation commissioner, Captain Manning is the first aviation commissioner of the ATSB. He is a former chief pilot at Qantas and the former president of the Australian and International Pilots Association. So he is very well-qualified in this area. With respect to my conflict of interest—or perceived or potential—Captain Chris Manning and the other aspect are being cared for by Pat Hornby, who is the manager of our legal services, so for any questions I will defer to those two...

Given the bizarre, micro-managing, high viz performance since that time, I now firmly believe that Hood was hired as Murky's 'Mandarin pick' as the perfect foil and Beaker replacement, for the continuing PelAir cover-up reinvestigation and indeed the MH370 SIO search cock-up and/or cover-up.

Like Beaker was most definitely the patsy to the Lord Sith of the Iron Ring, so to is there much evidence that Hoody is re-incarnated as the next voodoo Muppet to Dr A...

Here is another example of a perceived Hood 'COI' that could create further questions of ATCB independence and investigative probity. Remember this? 

(02-23-2016, 05:58 PM)Peetwo Wrote:  CASR 175 certification?

Apparently in a quiet moment less than a week ago, after a year of transition, the CASA AAD officially rubberstamped...err certified ASA under CASR 175.

Strangely this was done with little to no fanfare and with only a Hoody & Cromarty handshake happy snap taken for posterity:


Maybe it is just me but I would have thought this was a proud moment in the history of ASA..

I also find it 'passing strange' that Cromarty did not mention, while under questioning from the Senators at Estimates, that the AAD had (presumably) recently audited ASA in preparation for the rubberstamping of the CASR 175 certificate..   If he had of done that it may have allayed some of the Senator X recent lack of oversight concerns by CASA of ASA:

From the Senate Estimates it would also appear that everyone - ASA, CASA, Dick Smith & the Senators - except for the ATSB totally missed the incident reported in the Senate Estimates thread today:

(02-23-2016, 11:40 AM)Peetwo Wrote:  

(02-23-2016, 11:09 AM)Peetwo Wrote:  From off the 'bump in the night' thread post #269

Quote:"..Compared with other countries, in Australia you are almost in complete silence all the time. I have said to the air traffic controllers, 'But couldn't you do a little bit more of a workload and actually give us an air traffic control service where we need it?' And quite a few of the controllers have said to me, 'Well, of course we can, but don't tell anyone I told you that'! I fly to Ballina from time to time, and you get this superb service from Bankstown's air traffic control; you just do what you are told. You get told to taxi out to the runway, and you ask for a clearance for take-off, and you take off, and the controller says 'Turn right to 120 degrees', and you meet the airway, and he or she says 'Turn left' and you follow the airway under air traffic control. The most amazing thing is that as you get to 8½ thousand feet, that is the only place on the whole trip where you can actually run into somebody. Up at 45,000 feet the airways are separated, going towards Brisbane and to the right by about 10 miles, from the one coming the other way, and up at 45,000 feet where I fly it is very unlikely for anyone to be there anyway. But when you actually get down to below 8½ thousand feet, the statistics show that is where the mid-air collisions can happen and it is where you can run into a mountain. I then get told, as the pilot—and I am a single pilot when I fly the plane; I do not have a copilot to start writing down call signs—'Traffic is'. In the worst situation, I was given four other aircraft, because the Lismore approach happens to be mingled up with the approach to Ballina. I write down on my pad, 'Four planes', and then I change off onto the aerodrome frequency and I start calling these planes and trying to sort out where they are.

To an Aussie pilot, that is just normal; that is the way we do it. But if you are a pilot from another country you simply cannot believe that a leading aviation country in the world can have something that is so archaic. If we brought in some class E airspace, as planned 20 years ago, instead of the en route controller—it is not an additional controller—giving you traffic information on three or four aircraft the controller would look at his or her radar screen down to about 3,000 feet and below the radar screen they would look at their flight strips on the electronic display, and they would separate you. It is called procedural separation. They would say, 'Hold at 6,000 feet' or 'Do the approach', and they would say, 'I'm holding an aircraft on the ground to depart.'

What I find incredible is that after 20 years we have not gotten even one airport in. And I have said to people who are against it—because resistance to change is staggering—'Let's just try one; if it is going to require hundreds of extra controllers then we obviously cannot afford it.' But my advice is that it will not. To the pilots who say they do not need it I say that I think after flying in it for three or four months you will find that it is a fantastic system.."

  

Okay now reflect on the summary from ATSB investigation AO-2016-003:

Quote:In preparation for departure from Ballina/Byron Gateway Airport, New South Wales the crew of Airbus A320, registered VH-VQS, was in radio contact with the crew of two arriving aircraft. After establishing the intentions of the arriving aircraft, VH-VQS entered the runway and lined up. While holding prior to take-off, the crew of VH-VQS clarified their plan for maintaining altitude separation with the crew of one of the arriving aircraft. This delayed the departure of VH-VQS and resulted in the second arriving aircraft being closer to VH-VQS than anticipated as it commenced take-off. During the initial climb out, the crew of VH-VQS realised the second aircraft was closer than anticipated and reduced the rate of climb in response. After re-establishing the separation plan, the crew recommenced the climb and departed.

The investigation is continuing.

This incident may turn out to be a storm in a teacup, however the fact that the ATSB is actually investigating would seem to indicate there is a little more to it than the summary suggests??

 

Keeping the above in mind, today I note that the ATSB investigation AO-2016-003 final report has ( yawn) finally been released:

Quote:What happened

On 14 January 2016, whilst taking-off from Ballina/Byron Gateway Airport, Airbus A320, registered VH-VQS (VQS) and operated by Jetstar Airways, came in close proximity to Beech Aircraft Corporation BE-76 Duchess, registered VH‑EWL (EWL). The Duchess was conducting navigation training in the vicinity of the runway and was noticed by the flight crew of VQS during the take‑off roll and below the maximum speed from which they could stop.

The take-off was continued and while manoeuvring to maintain separation from EWL, the crew of VQS received master warning/caution alerts regarding the aircraft’s configuration. The crew also commenced flap retraction at low altitude and turned contrary to operator-prescribed departure procedures before departing for Melbourne. There were no injuries or damage to equipment recorded during the occurrence.

What the ATSB found

The ATSB found that despite an increase in passenger numbers and a mixture of traffic, Ballina/Byron Gateway Airport operated without the support of air traffic information and/or services. While recognising that a direct comparison between airports is difficult, Ballina also experienced a higher number of incidents relating to communication and separation issues compared to airports with similar traffic levels. The ATSB also found that a number of non‑standard operating practices and procedures led to a breakdown of crew resource management and the ability to adequately manage the dynamic situation by the crew of VQS. Finally, the ATSB found that the level of communication between the crews of VQS and EWL was inadequate to develop a shared mental model of what each crew was intending to do to ensure separation.

What's been done as a result

Following a recommendation by the Civil Aviation Safety Authority (CASA), the operator of Ballina/Byron Gateway Airport implemented a certified air/ground radio service (CA/GRS) to provide weather services and traffic information at the airport. This service commenced in March 2017 and operates daily between 0800 and 1800 local time. The CASA Office of Airspace Regulation is planning a post‑CA/GRS implementation review in mid-2017 to assess its effectiveness.

Additionally, Jetstar Airways have proposed to increase their annual audit schedule of common traffic advisory frequency operations, reviewed their jump seat policy when operating in such aerodromes to assist in distraction management, and altered their training matrix to further include exercises pertaining to levels of assertion and upwards managing by first officers.

Safety message
Operations at non‑controlled airports remain a safety watch priority for the ATSB. This occurrence highlights that traffic separation in that environment relies on a clear and shared plan between involved aircraft.

Adherence to standard operating practices and procedures promotes a shared understanding of crew’s actions by making them ordered and predictable to the other pilots. As well as reducing the likelihood of task omission or duplication during times of high workload, standardised practices and procedures decrease the mental demand on flight crew when carrying out a set of complex steps, allowing for better processing of unexpected events.

---

Findings


From the evidence available, the following findings are made with respect to the traffic management occurrence involving Airbus A320, registered VH-VQS and operated by Jetstar Airways, and a Beech Aircraft Corporation Duchess BE-76, registered VH-EWL that occurred at Ballina/Byron Gateway Airport, New South Wales on 14 January 2016. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Safety issues, or system problems, are highlighted in bold to emphasise their importance. A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area. [Safety Issue]
  
• In addition to conducting the pilot flying role, the captain of VH-VQS assumed control of the radio to ensure separation with the incoming aircraft VH-VUE. This increased the captain's workload, resulting in reduced positional awareness of the more proximal VH-EWL and a subsequent traffic conflict with that aircraft.
  

Other factors that increased risk

• The non-adherence to standard operating procedures by the captain of VH-VQS, although possibly influenced by a desire to expedite the take-off, was consistent with a steep cockpit authority gradient. This resulted in a lack of crew shared understanding and distraction, removing the opportunity for the first officer to identify the impending traffic conflict.
  
• Despite a positive separation plan between VH-VUE and the two other aircraft, no such plan was established between the pilots of VH-EWL and the crew of VH-VQS. This led to the pilots of VH-EWL expecting VH-VQS to remain in the line-up position until after VH-EWL had completed the missed approach and therefore not perceived as a conflict threat.
  
• The radio call to inform Ballina/Byron Gateway traffic that VH-VQS was rolling was transmitted after the take-off roll had commenced. This limited the opportunity for the instructor in VH-EWL to process the situation and ensure adequate separation.
  
• The decision by the crew of VH-VQS to remain below VH‑EWL’s operating altitude after take‑off, although intended to assure adequate separation until sufficient lateral separation was established, resulted in non‑standard handling of the aircraft and the activation of a number of master warning/caution alert
  

Safety issues and actions

The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The Australian Transport Safety Bureau (ATSB) expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.

The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Air traffic facilities at Ballina/Byron Gateway Airport

Safety Issue: AO-2016-003-SI-01
Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.

  

"..Q/ So did Hoody declare himself possibly conflicted with this investigation as well?? .."

Quote:Media release

Title - ATSB Chief Commissioner Greg Hoods talks traffic management
 
Date: 19 May 2017

ATSB Chief Commissioner Greg Hoods talks about the traffic management occurrence involving Airbus A320, VH-VQS and Beech Aircraft Corporation BE 76, VH-EWL at Ballina/Byron Gateway Airport, NSW on 14 January 2016.

ATSB investigation AO-2016-003
 
Media contact: 1800 020 616
 


Last update 19 May 2017 

Hmm...guess that would be a resounding NO!       

 Same story same mantra - FASA/ASA/ATCB joint presser:

"Nothing to see here move along" - Just ask Hoody...   

MTF...P2  

Ps Noticed that Hoody by wearing multiple hats, has saved enough ATP funds to enable him to actually employ a few more minions:

Quote:The ATSB has a number of exciting opportunities to work in a range of roles across the organisation. Check it out:



http://www.atsb.gov.au/about_atsb/employment/

---

RE: The search for investigative probity. - Gobbledock - 05-20-2017

Hood is an arrogant Muppet. He has no care or concern about 'conflicts of interest' because these people genuinely and proudly couldn't care less about any sort of moral compass. They know they are untouchable and coated in 18 layers of teflon. The entire system of government is rigged at all levels. Transparency, accountability and honesty? Tell em their dreaming.

As for Hoods little speech, get me the spew bucket. Make that two. As an old timer once told me;

"I was not put on this earth to take orders from assholes".

Tick Tock Hi-vis Greg.

---

RE: The search for investigative probity. - Peetwo - 06-01-2017



High viz Hoody front & centre yet again - err why?

I note that, in relation to the ATSB opened AAI into the fatal Rossair Conquest training accident near Renmark (see HERE), that the ATSB notified via a media statement yesterday that the micromanaging CC Hoody will once again be turning up in his matching high viz jocks, socks and vest to conduct a media briefing :

Quote:Media release

Title

Media briefing on fatal aviation accident at Renmark, SA
 
Date: 01 June 2017

ATSB Chief Commissioner Greg Hood and SA Police Superintendent James Blandford will provide an on-site media briefing at 11 am (ACST) Thursday, 1 June 2017, at the location of the Renmark aviation accident in South Australia.

Three people died when a Cessna Conquest 441 aircraft, registered VH-XMJ, collided with terrain at 4.30 pm on Tuesday 30 May 2017. The accident occurred about 4 km west of the Renmark airport.

The briefing will outline the known facts of the accident, the investigation team’s on-site activities and the investigation process.

ATSB investigation AO-2017-057

Who:       ATSB Chief Commissioner Greg Hood
               SA Police Superintendent James Blandford

Where:    SA Police Forward Command Post — proceed along Sturt Highway, turn onto
               Santos Road (dirt road), travel 5 km, turn left at the witches hat and
               proceed to Forward Command Post

When:    11 am ACST, Thursday 1 June 2017

Media contact: 1800 020 616
 


Last update 31 May 2017

        
Q/ Does this indicate that Hoody has indeed sacked the ATSB media spokesperson?
Q/ Was the Hood appearance at the request of the IIC? If so wouldn't it be more appropriate for the GM of AAI to field questions and provide briefing of a potentially technical nature?
Q/ Does this mean that Chief Commissioner Hood will appear at all future media briefings of all fatal accident investigations? 
The cynical part of me believes, that because Hoody is really a reincarnation of Beaker, that his appearance at such briefings signifies potential sensitivities in an AAI that may require his top-cover expertise...

Just saying -


MTF...P2 .

P7 (poach) - And very well said indeed good Sir. 

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RE: The search for investigative probity. - Peetwo - 06-01-2017

(06-01-2017, 10:38 AM)Peetwo Wrote:  

High viz Hoody front & centre yet again - err why?

I note that, in relation to the ATSB opened AAI into the fatal Rossair Conquest training accident near Renmark (see HERE), that the ATSB notified via a media statement yesterday that the micromanaging CC Hoody will once again be turning up in his matching high viz jocks, socks and vest to conduct a media briefing :

Quote:Media release

Title

Media briefing on fatal aviation accident at Renmark, SA
 
Date: 01 June 2017

ATSB Chief Commissioner Greg Hood and SA Police Superintendent James Blandford will provide an on-site media briefing at 11 am (ACST) Thursday, 1 June 2017, at the location of the Renmark aviation accident in South Australia.

Three people died when a Cessna Conquest 441 aircraft, registered VH-XMJ, collided with terrain at 4.30 pm on Tuesday 30 May 2017. The accident occurred about 4 km west of the Renmark airport.

The briefing will outline the known facts of the accident, the investigation team’s on-site activities and the investigation process.

ATSB investigation AO-2017-057

Who:       ATSB Chief Commissioner Greg Hood
               SA Police Superintendent James Blandford

Where:    SA Police Forward Command Post — proceed along Sturt Highway, turn onto
               Santos Road (dirt road), travel 5 km, turn left at the witches hat and
               proceed to Forward Command Post

When:    11 am ACST, Thursday 1 June 2017

Media contact: 1800 020 616
 


Last update 31 May 2017

        
Q/ Does this indicate that Hoody has indeed sacked the ATSB media spokesperson?
Q/ Was the Hood appearance at the request of the IIC? If so wouldn't it be more appropriate for the GM of AAI to field questions and provide briefing of a potentially technical nature?
Q/ Does this mean that Chief Commissioner Hood will appear at all future media briefings of all fatal accident investigations? 

The cynical part of me believes, that because Hoody is really a reincarnation of Beaker, that his appearance at such briefings signifies potential sensitivities in an AAI that may require his top-cover expertise...

Just saying -


MTF...P2 .

P7 (poach) - And very well said indeed good Sir. 

Ps In case you were wondering how Hoody's media briefing went - - here is a summary courtesy of ABC news online:

Quote:Rossair flight only in air for seconds before crash near Renmark, investigators believe
By Sarah Scopelianos and Tom Fedorowytsch

Updated about 6 hours ago
Thu 1 Jun 2017, 1:57pm


Photo: Australian Transport Safety Bureau staff have taken over the site from police. (ABC News)
Related Story: Rossair chief pilot among dead in Riverland plane crash

Map: Renmark 5341

The doomed Rossair flight, which crashed near Renmark killing three experienced pilots, had only just taken off from the nearby country airport, authorities have said.

Australian Transport Safety Bureau (ATSB) chief commissioner Greg Hood said the plane had left Adelaide for Renmark on Tuesday afternoon and had landed at the Renmark Airport.

He said the aircraft was only in the air for 60 to 90 seconds after take off from the airport before it hit Mallee scrub.

The strong smell of fuel led emergency service personnel to the crash site.

Mr Hood said the crash site had been handed to the bureau's five investigating officers this morning by SA Police.

Officers had identified hazards at the site and were conducting laser mapping of the area, Mr Hood said.

Paul Daw, 65, Rossair's chief pilot Martin Scott, 48, and Civil Aviation Safety Authority (CASA) representative Stephen Guerin, 56, were killed when the Cessna Conquest with the registration VH-XMJ crashed.

Mr Hood said it would be a "complex investigation".

Photo: ATSB chief commissioner Greg Hood speaks to the media. (ABC News)

"We don't see these types of accidents very often in Australia," he said.

"I think for the past 30 years or so we have not seen a serious accident involving the Conquest aircraft or in fact a Rossair or their predecessor Air South.

"This crash site is concentrated. It's about 40 metres all in all and so that tells us potentially the aircraft has gone in a reasonably steep rate of descent."

Some debris was found further afield from the main crash site.

Mr Hood was asked about what sort of training exercises were being conducted during the check and training flight and whether they included a simulated engine failure, but he said he could not comment.

"The investigation will try and discover what type of airwork was being conducted, but it is too early to say yet whether that was the likely cause [of the accident]."

The 10-seater plane was not required to have a cockpit voice recorder or flight data recorder.

Mr Hood said the crew had failed to contact air traffic control by a designated time and at about the same time a satellite picked by the aircraft's electronic locator beacon, which is activated on impact.

Flight history, the aircraft and its national and international safety record, maintenance and pilot records, data from air traffic control system and whether any final calls were made on the local air traffic control system will be looked at.

Several people saw the plane climbing out of Renmark in its final moments.

Investigators are expected to remain at the site for several days.

Pps Interestingly enough when the ABC News first cut to high viz Hoody in the bush they ended up reporting that CC Hood was one of the ATSB investigators -

Hmm...maybe that is the image that Hoody really craves -

FWIW as a media stooge Hoody held up alright...

---

RE: The search for investigative probity. - Gobbledock - 06-02-2017

I see that the style guru keeps with tradition and is still wearing the hi-vis vest!
I wonder if he has a toga and leather chaps in the bright green colour? Perhaps he also has a thong in the same colour?

'Safe hi-vis styling for all'

---

RE: The search for investigative probity. - Sandy Reith - 06-03-2017

I take it that there's others who find it extraordinary that ATSB CEO Mr Hood is on the scene as an investigator. Along with no less than five other investigators who will be there for a reported several days.
Do the CEOs of like government organisations in Australia or other countries involve themselves in field work?
I can't believe that this is bone fide CEO's work; and why the hi-vis jacket? Wouldn't his underlings know who he is?
I don't get it, am I missing something? To me it's really peculiar.

---

RE: The search for investigative probity. - Gobbledock - 06-03-2017

Hoody is a control freak and narcissist. Probably thinks only he is capable of performing the task adequately. And don't forget, Hoody is not the Messiah of accident investigations and he is not a lifetime accident investigation qualified person. Remember he flies privately for fun and worked in ATC. He sucked his way through CAsA and ASA to end up at ATsB as the grand wizard. Just because he is the boss of the ATsB it doesn't mean there is nobody better skilled than he. My guess is he is learning how to become an accident investigator, hence his being on site.

As you say Sandy, why the hell else would the hi-vis wearing Muppet be in the thick of it?

---

RE: The search for investigative probity. - Peetwo - 06-17-2017

Charitable Hoody - Pretty in pink.

(06-03-2017, 06:56 PM)Gobbledock Wrote:  

Quote:Sandy: I take it that there's others who find it extraordinary that ATSB CEO Mr Hood is on the scene as an investigator. Along with no less than five other investigators who will be there for a reported several days.

 Do the CEOs of like government organisations in Australia or other countries involve themselves in field work?

I can't believe that this is bone fide CEO's work; and why the hi-vis jacket? Wouldn't his underlings know who he is?

I don't get it, am I missing something? To me it's really peculiar.

Hoody is a control freak and narcissist. Probably thinks only he is capable of performing the task adequately. And don't forget, Hoody is not the Messiah of accident investigations and he is not a lifetime accident investigation qualified person. Remember he flies privately for fun and worked in ATC. He sucked his way through CAsA and ASA to end up at ATsB as the grand wizard. Just because he is the boss of the ATsB it doesn't mean there is nobody better skilled than he. My guess is he is learning how to become an accident investigator, hence his being on site.

As you say Sandy, why the hell else would the hi-vis wearing Muppet be in the thick of it?

Sandy & Gobbles, perhaps our wannabe 'high profile' Chief Commissioner has taken your comments onboard...

I note that yesterday with the announcement that the ATSB will be investigating yet another tragic fatal accident - Ballina fatal: Possible inadvertent IMC - RIP! - that was this time the CC did not act as spokesperson, nor did he indicate (via social media) that he will be again taking part in the investigation:

Quote:The ATSB is investigating a fatal aircraft accident involving a Cessna 172 near Ballina NSW 16 June 2017. More: http://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-061/ …pic.twitter.com/hYsoCRCjhY

---

Summary

The ATSB is investigating a fatal aircraft accident involving a Cessna 172 aircraft, registered VH-FYN, that occurred about 12km WNW of Ballina, NSW on 16 June 2017.

The aircraft collided with terrain and the pilot, the only person on board, was fatally injured.

The ATSB has deployed a team of four investigators to the accident site with expertise that includes aircraft engineering and maintenance.

While on site the team will be examining the site and wreckage, gathering any recorded data, and interviewing any witnesses.

The ATSB will provide an update on its website outlining the facts of the accident within 30 days.
 
General details
Date: 16 June 2017
 
Investigation status: Active
 
Time: 8:45 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Rishworths Lane, Brooklet
 
Occurrence type: Collision with terrain
 
State: New South Wales
 
Occurrence class: Operational
 
Occurrence category: Accident
 
Report status: Pending
 
Highest injury level: Fatal
 
Expected completion:June 2018
 
 
Aircraft details

Aircraft manufacturer: Cessna Aircraft Company
 
Aircraft model: 172M
 
Aircraft registration: VH-FYN
 
Serial number: 17267270
 
Type of operation: Private
 
Sector: Piston
 
Damage to aircraft: Destroyed
 
Departure point: Heck Field, Qld
Destination: Ballina/Byron Gateway, NSW
 
 
 


Last update 16 June 2017

P2 comment: Saving grace with this AAI is that the inestimable NSW Police Airwing will be investigating on behalf of the Coroner...

In fact Hoody was apparently promoting a good cause where all good CEO's should be - 'pretty in pink' at his desk...

Quote:ATSB Chief Commissioner Greg Hood today got pinked for Real men wear pink week. https://realmenwearpink.gofundraise.com.au/page/ATSB17 pic.twitter.com/LASh3sgICL

And a couple of days before being even more 'executive' and 'chief'...

Quote:Help ATSB Chief Commissioner Greg Hood fight homelessness. Donations to the Vinnies CEO Sleepout appreciated. https://www.ceosleepout.org.au/ceos/act-ceos/greg-hood/ …

Err...one comment -  

Quote:https://realmenwearpink.gofundraise.com.au/page/ATSB17

Greg Hood

Donated $50.00 in support of ATSB 2017

For a bureaucrat who is on upwards of 400K a year $50 is a bit piss poor


MTF...P2

---

RE: The search for investigative probity. - P7_TOM - 06-20-2017

Dear P2.

You’d have laughed your socks off last evening; you finally did it –. Ambled into the workshop, the ‘armoire’ was being carefully dissected; silence reigned, - bar one dog snoring quietly, asleep on an old rug it has claimed, t’uther closer to the stove, bone between front paws. The assembly bench lit, the rest in shadow and firelight. “Hiya” came from a voice from somewhere behind the forearms and hands I could see – “Wotcha” says I – “Ale?”. Silly question, I know. So, there we were in the ancient armchairs, feet up, glass close at hand, a short discussion on mutilated dovetail joints and remedy for same and – blessed quiet.

“Seen this” says I after a spell – showed him a print out of the latest “Hood” media appearance. The dogs gave it away first – one woke, the other stopped chewing; all eyes focussed on the hand which stopped moving halfway between table and target – before the glass being very gently set back down. I’ve never seen anything that ever stopped that action – “Darts practice” says he – picking up the photo and placing it – carefully – into the fire.

W – T – F came out, each word punctuated by a dart – Then the nursery rhymes – Little Boy Blue, Ring-a-Ring of Rosie’s, Little Miss Muffett, Little Bo Peep, Goosey goosey gander. One crafted for each idiot, all completely unprintable; one even in Persian – for the richness of language, you understand. The “K” version of ‘Mary had a little lamb’ had me in tears of laughter. Ridicule is the only anodyne – “Can’t take this seriously” says he “ FDS make's us as ridiculous as they are – Duck ‘em, hard and often”

So there you have it P2 – you have achieved a new definition of ‘Pink Bat’s’ – past value , current prospects and future worth. Laughed and talked, made up new lines, used up some imagination – ended up sore from laughing. Bottom line - what else can you do? The antics, pretensions and unbridled ego’s of our top draw ‘managers’ of the aviation ‘system’ merit little else but our derision, disgust and mockery. Which of course reflects on the idiot running the asylum. Daren 6D’s crew – WTF is he using for brains – porridge?    

L&K P7.

PS. Try not to put ‘that’ picture up again – honest; I wouldn’t….(just saying).

---

RE: The search for investigative probity. - Gobbledock - 06-20-2017

P2;

For a bureaucrat who is on upwards of 400K a year $50 is a bit piss poor

P2, that's a low ball offer mate. Bump it up to over $600k and you are closer to the mark.

It was interesting seeing him support the 'pink'. It's not a colour he is usually interested in. Now if the colour had been brown...................

---

RE: The search for investigative probity. - Peetwo - 06-23-2017

Hoody issues SR for Caboolture C206 fatal accident -  

Via the ATSB news webpage:

Quote:Fatal accident prompts safety recommendations for skydiving operations

A multi-fatal accident involving a Cessna U206G aircraft has resulted in the ATSB issuing recommendations to improve the safety of skydiving operations in Australia.

https://www.atsb.gov.au/media/5773102/caboolture_gh_22june2017-1.mp4

The 22 March 2014 accident occurred when the aircraft was conducting tandem parachuting operations at Caboolture in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists.

Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground. Tragically, all five died in the accident.

ATSB Chief Commissioner Greg Hood said the investigation report, released today, reveals that extensive fire damage prevented examination and testing of most of the aircraft components.

“Due to the post-impact damage to the aircraft, we couldn’t rule out a mechanical defect as a contributor to this accident,” Mr Hood said.

“Importantly, our investigation did uncover a number of safety issues associated with occupant restraint, modification of parachuting aircraft and scope for improving the risk controls associated with parachuting operations.”

In response to the ATSB’s investigation, the Australian Parachute Federation (APF) and Australia’s aviation safety regulator, CASA, undertook action to improve safety of parachuting operations.

“The APF mandated that all member clubs/operations have their own safety management system to proactively assess and mitigate risks. The APF has also enhanced their audit process and increased the number of full-time safety personnel to audit their member organisations.” Mr Hood said.

“The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co-pilot side flight control modifications.

“We welcome APF’s and CASA’s safety action but consider more can be done to improve safety for skydiving operations.”

In response to an identified safety issue, the ATSB recommends that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification. This safety issue affects all Cessna Aircraft and not just those being used for parachuting operations.

In addition, it is recommended that CASA introduce measures to reduce the risk associated with the aviation aspect of parachuting operations.

As well, the ATSB recommends CASA and the APF increase the use of dual-point restraints in parachuting aircraft.

Under legislation, APF and CASA have 90 days to respond to the ATSB’s recommendations.

Read the full investigation report AO-2014-053
 



Last update 23 June 2017

 
MTF...P2

---

RE: The search for investigative probity. - Peetwo - 06-26-2017

(06-23-2017, 03:32 PM)Peetwo Wrote:  Hoody issues SR for Caboolture C206 fatal accident -  

Via the ATSB news webpage:

Quote:Fatal accident prompts safety recommendations for skydiving operations

A multi-fatal accident involving a Cessna U206G aircraft has resulted in the ATSB issuing recommendations to improve the safety of skydiving operations in Australia.

https://www.atsb.gov.au/media/5773102/caboolture_gh_22june2017-1.mp4

The 22 March 2014 accident occurred when the aircraft was conducting tandem parachuting operations at Caboolture in Queensland. On board were the pilot, two parachuting instructors and two tandem parachutists.

Shortly after take-off, the aircraft climbed to about 200 feet before aerodynamically stalling and colliding with the ground. Tragically, all five died in the accident.

ATSB Chief Commissioner Greg Hood said the investigation report, released today, reveals that extensive fire damage prevented examination and testing of most of the aircraft components.

“Due to the post-impact damage to the aircraft, we couldn’t rule out a mechanical defect as a contributor to this accident,” Mr Hood said.

“Importantly, our investigation did uncover a number of safety issues associated with occupant restraint, modification of parachuting aircraft and scope for improving the risk controls associated with parachuting operations.”

In response to the ATSB’s investigation, the Australian Parachute Federation (APF) and Australia’s aviation safety regulator, CASA, undertook action to improve safety of parachuting operations.

“The APF mandated that all member clubs/operations have their own safety management system to proactively assess and mitigate risks. The APF has also enhanced their audit process and increased the number of full-time safety personnel to audit their member organisations.” Mr Hood said.

“The Civil Aviation Safety Authority (CASA) has increased the available information on their website about the risks associated with sports aviation. CASA also introduced an Airworthiness Bulletin to provide guidance about co-pilot side flight control modifications.

“We welcome APF’s and CASA’s safety action but consider more can be done to improve safety for skydiving operations.”

In response to an identified safety issue, the ATSB recommends that CASA take safety action to increase the fitment of the Cessna secondary pilot seat stop modification. This safety issue affects all Cessna Aircraft and not just those being used for parachuting operations.

In addition, it is recommended that CASA introduce measures to reduce the risk associated with the aviation aspect of parachuting operations.

As well, the ATSB recommends CASA and the APF increase the use of dual-point restraints in parachuting aircraft.

Under legislation, APF and CASA have 90 days to respond to the ATSB’s recommendations.

Read the full investigation report AO-2014-053
 



Last update 23 June 2017

 

Update: Via the Brisbane Times...

Quote:June 26 2017 - 9:32PM

Safety lessons learned from fatal skydiving plane crash at Caboolture Airfield

• [/url]Toby Crockford
  [url=http://www.brisbanetimes.com.au/queensland/by/Toby-Crockford-gr3iis]
  

Three years ago, a light plane carrying skydivers stalled shortly after takeoff and plummeted to the ground, resulting in an inferno at Caboolture Airfield that killed five people.

After extensive investigations by the Australian Transport Safety Bureau, a number of safety issues were identified regarding the pilot seat and skydiver restraints.

The aftermath of the skydiving plane crash at Caboolture Airfield which killed five people in 2014. Photo: Seven News  

A pilot, two skydiving instructors and two amateur skydivers perished when the Cessna U206G aircraft, registered VH-FRT, crashed and burst into flames on the morning of March 22, 2014.

The victims were Beenleigh couple Joseph King and Rahi Hohua, experienced instructors Glenn Norman and Juraj Glesk and young pilot Andrew Aitken. 

Related Content

• 
  Caboolture plane crash remains a mystery
  
  

The final report into the crash was released by the ATSB on Friday and despite not determining a cause of the crash, mainly due the almost complete destruction of the fuselage, it did make several significant safety recommendations.

Despite being mandatory, according to the aircraft manufacturer, for the pilot's seat to have a secondary seat stop modification to prevent movement and potential loss of control, it was not fitted to the light plane and was not required Australian regulations. 

Some Cessna 206 parachuting aircraft, including VH-FRT, also had their flight control systems modified without proper checks or approvals and this increased the risk of flight control obstruction.

 

MTF...P2

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RE: The search for investigative probity. - P7_TOM - 07-05-2017

Sandilands lets another one past to the keeper; rhetoric, without a push in the right direction is used to sell advertising; not reform.

“A loss of situational awareness in failing light approaching an airport is never funny, nor trivial”.

No kidding – and no report worth a tinkers cuss; no changes mark you; just some fluff about:-

“The report outlines the steps REX has taken to prevent such a stuff up in the future.”

It is time both ATSB and CASA got to grips with the situations their ‘philosophy’ and tinkering with established good practice were examined – in detail; and amended immediately.  Not funny – WTD more like – ‘configured for landing? Six miles south of the bloody airport –

John Sharpe rules – OK; with an Iron Bar. Still the ‘minister’ running the show along with his ‘mates’ in high places. Bollocks

---