[Peetwo]

..TM raises one of the major items the ATSB hesitates to approach.   Remember who approves/ accepts procedures and checklists.  For students a critical area; who knows,  had the GA been executed as per the manufacturer procedures used during certification the accident would. perhaps, never have occurred.  But I forget, the average CASA FOI knows truck loads more that the manufacturer and their test pilots, sorry my bad...

..Bravo TM, spot on and damn right.   But of course ATSB ain't going to step up to mark and say it is very wrong to teach a homemade, but approved system for a critical flight sequence – the fellah was sick don'tcha know.   Well, that's Avmed back in the spotlight.  

What a cluster of ducks.  

Indeed so here we have another classic ATSB report that when put to a cursory review by peers in the industry is found desperately wanting and suspiciously edited for Political correctness...

From the report:

Operational information

Go-around procedure

A go-around may be initiated by a pilot when an aircraft is on an approach to land. A go-around is intended to change an aircraft’s flight profile from descending in an approach or landing configuration to a climb in a climbing configuration. A go-around procedure is considered a normal procedure and, although it is not often required, it should not result in increased risk.

The operator was unable to provide the ATSB with the go-around procedure that was in use at the time; however, the procedure that was effective from November 2013 is shown in Figure 5. This procedure was consistent with that published by Cessna.

Figure 5: Go-around procedure
(see report)
Source: Aircraft operator

The flying school taught students that when their aircraft was descending through a height of 300 ft above ground level on approach to land, the pilot should initiate a go-around unless the:

• aircraft was within 10 kt of the correct airspeed

• aircraft was established on the extended runway centre-line

• approach profile was aligned with the visual approach slope indicator

• aircraft was configured to land.

Flap settings

The aircraft’s wing flaps were found to have probably been in the fully-extended, 40° position at impact. The instructor who approved the student pilot for night solo circuits that night reported that the student had been trained and observed to conduct landings at night with a maximum of 20° flap extension.

It was further reported that students were trained to use full flap extension in certain circumstances, including short-field landings and practice forced landings during the day.

Practice forced landings would include a go-around from the full flap extension configuration. According to the flying school’s integrated training syllabus, practice forced landings were not conducted at night.


At 40° flap extension, the aircraft can be flown at a particular airspeed with a lower nose attitude than when conducting the same manoeuvre with a lesser degree of flaps, or with flaps retracted.

Cessna advised that a go-around from a trimmed approach with 40° flap extension would require about 20 kg of forward control yoke force to maintain 55 kt. About 25 kg of forward control yoke force is required at 20° flap extension in the same scenario. Cessna also advised that on the night, the aircraft’s climb performance at 40° flap extension would have been about half that expected if the flaps had been fully retracted.

It was reported that the pilot was trained to retract the flaps in 10° stages during the go-around, removing the force required on the control yoke. 

 
Although only cursory the investigators have examined the Operators FCOM etc. to establish what the cadet trainee had been taught for a SE GA (as per above). However as TM points these procedures were contrary to the procedures as outlined in the manufacturer's AOM. In any normal AAI that should automatically make it into at least the contributory factors section of the report. So let us have a look:  

Findings

From the evidence available, the following findings are made with respect to the loss of control and collision with terrain involving Cessna Aircraft Company 182R, registered VH-AUT, which occurred near Hamilton Airport, Victoria on 23 September 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• Following a go-around during night circuit consolidation training the aircraft departed controlled flight and collided with terrain.

Other factors that increased risk

• The pilot had an undiagnosed heart anomaly that predisposed him to a cardiac event and incapacitation.

• For reasons that could not be conclusively determined, the Civil Aviation Safety Authority was unaware of the student's prior treatment for attention deficit hyperactivity disorder, preventing its consideration and management of any ongoing safety risk associated with the condition.

Other findings

• Post-mortem examination was unable to completely exclude the possibility that the accident was precipitated by a cardiac event.

   
FFS...nothing, not a dicky bird - instead the Beakerised TL/Reviewers/GM & Commissioners go off on some wild goose chase about some pilot medical issues that may/or may not remotely have contributed to the accident...

As a result the media jumps all over the medical condition part alone and before you know it...

Report finds trainee pilot killed in plane crash near Hamilton had undisclosed heart condition


Updated Fri at 1:08pmFri 8 May 2015, 1:08pm


An investigation into a fatal plane crash in Hamilton, in south-west Victoria, has revealed the pilot's medical condition may have led to the incident.

A 20-year-old trainee pilot from New South Wales was killed when the single-engine Cessna 182 crashed into a paddock north of Hamilton in 2013.

A report by the Australian Transport Safety Bureau found the pilot had an undisclosed congenital heart anomaly "capable of causing incapacitation" and that may have "contributed to the development of the accident".

The report recommends a "shared responsibility" between pilots, doctors and the Civil Aviation Safety Authority in reporting, assessing and managing medical conditions.

 
Wonder what it will be this time next week..

"Trainee Pilot flagrantly ignored authorities by not reporting known medical conditions..blah..blah.."

MTF...P2       

[Gobbledock]

What an absolute crock of shit report! Thank you ATSB, this was written for my grandkids primary school class, they now know what a go-around is! FFS! Why doesn't Beaker fill the report with an additional 80 pages explaining what an aircraft wheel does as well? Perhaps discuss what a nose lamp does, or how about an engine oil explanation on how the oil lubricates engine parts, maybe include an analysis of what a pilots seatbelt does, and to round out their non-robust pony pooh report they could explain the purpose behind an aircrafts windscreen wiper!!!!!

I would find a medical study about Truss's anal mucous more enlightening than the 'Beakerfied non intelligent beyond reason rabble' that this embarrassing beard on/beard off Canrberra muppet signs off on.
This investigation report has been graded with an S- (shit minus) by the IOS at this afternoons 'BRB nude Twister championships', which incidentally ended in a draw between the Ferryman and half-baked. Farmer Truss snuck into the main event disguised as a Scarecrow but was disqualified for tripping over his own saggy balls. (The only other time such a low mark has been awarded was for Dr Aleck's Just Culture speach and Looklefts ASSR submission).

"Foolish, non-germane shite reports for all"

[Kharon]

Second reading – Steam On.

P2 – has Manning been 'officially' appointed, or is that just a whisper on the wind?  Do we know?

The ATSB report mentioned above is actually dangerous, a very real safety hazard.   ATSB should make no bones about dragging aircraft operations back to 'law'.  The law is as it stands now is very, very clear about how an aircraft must, not should or may, but MUST be operated in compliance with the manufacturer flight manual.  Cessna go to some trouble and expense to get an aircraft certified, many Cessna variants have speed and configuration differences for each Mark and model; defined through the certification test flight process and documented in the Manufacturer Aircraft Flight Manual: (AFM).  You need a 'No Objection' from the manufacturer to operate outside the AFM, or you are not only illegal, but at hazard; as demonstrated in the accident mentioned above.

Here we find a flight school promoting not only a one size fits all approach to training, which will set a dangerous precedent in a students mind, one which will remain as a foundation for future 'learning', but also a serious compromise of the AFM, which again, teaches more bad basic habits at an early stage.   CASA approve (or accept) those compromises, the ego feed and assumption of 'superior' knowledge being espoused rather than the 'law' and basic common sense.  When an accident occurs, as it must under these circumstances, CASA will simply roll back to the legal position and say, quite truthfully, "Oh, the pilot operated outside the AFM, this is illegal, and, if he weren't dead, we would do him as a being not a fit and proper for using homemade procedures".

ATSB should have driven a nail into this coffin, with a vengeance.   If Manning is in the job he does know better than this and should not be allowing ATSB to keep generating these slip-shod, inaccurate, dangerous reports.  It is wrong, it is dangerous, it is illegal – and that's just kissing the CASA arse; wait until an accident happens, watch 'em duck and weave then.

"What's that you say? – Oh, we've seen that show; is that the one where CASA approved dangerous, illegal practices and walked away Scot free.  Ah yes, I remember it now".

So, is Manning just warming a seat and collecting the loot, or not there?  Someone has to stop this farce, NOW, not at some point in the future bureaucratic time space continuum.  

Toot toot.... ...

[Peetwo]

Not sure about Manning, it could be that he is being distracted by higher profile investigations and hopefully he will get a chance to look at this more closely. Indeed the timing of the release of this report probably meant he would not have been part of the Commissioner's review process.

However I totally agree with Kharon's sentiments on this and cannot believe that this report has sailed through all the checks & balances (reviews/audits etc), all the way through to the Commissioner level without a single STSI, TSI, expert peer reviewer or DIP coming to a similar conclusion (although maybe not quite so animated.. ) as this...

"..should not be allowing ATSB to keep generating these slip-shod, inaccurate, dangerous reports.  It is wrong, it is dangerous, it is illegal – and that's just kissing the CASA arse; wait until an accident happens, watch 'em duck and weave then.."  

IMO the fact this report has been released without so much as a cursory mention of this significant safety issue (even in the 'Contributory Factors' section), should automatically have heads rolling all the way to an executive/Commissioner level.   

This AAI defective report, along with the PelAir report, are not one off aberrations. IMO there are real repetitive systemic issues here that need to be urgently addressed before similar incidents/accidents begin to reoccur due to lack of sufficient risk mitigation where organisational issues & regulatory oversight (or lack of) will be a contributory factor.

For the benefit of Mr Manning - & as a gentle reminder of the lighter end of town.. - have a close look at this report - AO-2010-111 - & this related post off the UP from Leadsled:

Folks,

As an example of how not to do it, read the ATSB report on the last one at Camden, a Twin Comanche, and study the photographs carefully. Read the whole report carefully, it is one short.

Credible eyewitness reports said the aircraft never got above 100-200ft.

Does the prop. on one engine look feathered to you!!

Consider the widely differing reports from the student and the instructor as to what actually happened, and what the aeroplane did, and figure out for yourself what "most probably" really happened.

In your considerations, take account of the AFM note about the fact that recovery from a spin is unlikely with full tip tanks.

Is it probable, given the verifiable facts, and the witness statements, that the CAAP was followed?
What action has CASA taken in this matter??
What pro-active action has ATSB taken, to find out why these accidents keep happening???
What action has ATSB taken to prevent, to the greatest extent possible, further similar fatal crashes --- I will not call them accidents????

Please, anybody, don't suggest I am saying "no asymmetric training", but let's drop the (I was almost going to say macho, but then I realised I know at least two female instructors who also indulge in the seriously risky practice of pulling the mixture "just off the ground") unnecessarily dangerous practices, to almost eliminate the chances of recovery, on the day it all turns to custard.

I was on the aerodrome at YSBK the day of the last fatal. That is not the only similar one at Bankstown when I have been on the aerodrome. Not long after I stated flying, I actually witnessed an Apache crash on an asymmetric missed approach, the PIC was the Piper agent Chief Pilot, fortunately, both lived. Not long after, a Heron crashed on the same airfield, same deal, attempting a physically impossible missed approach, all died, then a best mate died in yet another twin training accident.

I had a blazing row with the pilot responsible for the last fatal at Camden, about two weeks before that accident. The subject of the row was a very close go, virtually a rehearsal for the final fatal crash. We all know the PIC was a high time instructor, but he was an accident looking for somewhere to happen. Finally, it did.

Several people on previous posts have said that the accidents we have had have been inexperienced instructors ---- in every accident, of which I have all too direct knowledge, that was not the case, but all high time and "highly respected" "professionals". There was no shortage of experience on the flightdeck of the Braz at Darwin.The laws of physics and aerodynamics, underlined by real world "human factors" have no respect for hours in log books or popular reputations.

I never cease to be amazed at the ignorance of some very high time instructors of close acquaintance , all Grade 1s, three are ATOs, who, quite frankly, simply do not understand just how un-safe their "SOPs" actually are.

Just because you are still alive doesn't prove your practices are "safe".

The FAA recommendation on the subject make worthwhile reading, but in certain quarters in this country, FAA recommendation are treated with disdain ---- we know better ---- an attitude thoroughly discredited by our actual record.

A quote:

[i]Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect.[/i]

Tootle pip!!

 Then coming up in weight, category & operation (but still a training accident) have a close read of this report - AO-2010-019 - & watch the accompanying video translated to YouTube:

Then ask yourself how it is possible for such a tragic training sequence to occur, when all historical evidence suggests this was so out of character for a conscientious, experienced, company CAR217 approved C&T officer. Who reportedly always placed speed & safety buffers on all EFATO training & testing sequences - why the dramatic change?

So, is Manning just warming a seat and collecting the loot, or not there?  Someone has to stop this farce, NOW, not at some point in the future bureaucratic time space continuum.  

  
I seriously hope that Manning is not just another Commissioner Muppet Clone and that he is systematically & seriously sorting the wheat from the chaff at bureau HQ...

Either way I totally agree the farce needs to stop NOW!

MTF..P2

[Peetwo]

From Shame for Truss  thread, 1st from me:

So in a week and a half Dick's "Wake up Wazza" campaign has at least 'accelerated' the CASA Ballina Airspace review report. However why is it the role of a concerned private citizen to draw attention to a serious latent safety risk issue? Supposedly one of the primary functions of our - so called fully independent - transport safety watchdog the ATSB, is to mitigate safety risk issues, without fear nor favour, when such issues are brought to their attention.

However recent examples like the YMML/YMEN breakdown of comms incident; the still outstanding VARA ATR incidents; or the still pending Mildura fog incident final report etc.; would seem to indicate that the ATSB are no longer in the game of safety risk mitigation - unless of course it won't possibly offend anyone...FFS!

and then from Gobbles...

P2 posted this snippet from an article that involved comments from Lil Bill Burke;

"Mildura Airport chief executive Bill Burke yesterday dismissed comments from former Civil Aviation Safety Authority (CASA) chairman and prominent businessman Dick Smith who said it was “utterly ridiculous” that aircraft flying below certain heights at regional airports were not monitored by radar, leaving it was up to pilots to communicate with each other to avoid collisions".

Umm, hello, earth to Bill, where have you been hiding son? And you manage the airport!!!! OMG, wakey wakey hand off snakey. It appears that Bill knows everything, and experienced pilots such as Dick, plus other commercial pilots have it all wrong?? Sorry Bill, and your flying and aeronautical experience is???

Well to follow on from Mildura Airport CEO Bill Burke's dismissive comments of Dick Smith's concerns, there was also these comments from the Ballina Airport Manager today on the other Aunty - Clearing the air - Ballina Airport manager refutes safety concerns.
Suddenly everyone is an expert but notice that all the DIPs (including CASA) are abrogating their responsibility, liability & therefore potential future expense. Both airport managers rely on a previous clean record of no serious incidents/accidents in regards to potential aircraft collisions as a proven track record or safety case. However they have all effectively missed the point and neatly swallowed the Dick Smith bait in the process...

Quote from the original Ean Higgins article from the Weekend Australian:

One absurdity, according to Smith and Woodward, is that restrictive rules stop Australian airports from introducing a US system in which various service providers, such as fire and rescue officers, provide pilots flying in the area with local weather and traffic information.

      
Which brings me back to the Mildura fog incident:

 Which apparently was recently updated yet again :

Updated: 22 May 2015



As part of its normal procedures, the ATSB has completed its initial review of the investigation and draft investigation report. Additional analysis is underway as a result of this review to further understand the implications for safety of the occurrence. Additional evidence has also been collected and work is underway to integrate relevant aspects of ATSB research investigation AR-2013-200 into the draft report. This will ensure a full understanding by readers of the reliability of Bureau of Meteorology meteorological products and the provision of this information to flight crew and operators.

The draft investigation report is now anticipated for release to directly involved parties (DIP) for comment in the third quarter of calendar year 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in the fourth quarter of 2015.

   
UFB...  

Q1/ Why is it that such obvious, serious, latent safety issues - that even Blind Freddy can see - have not led to the ATSB promulgating Safety Recommendations for this incident?
 
Q2/ Why is it that with these weather related incidents/accidents (which includes the PelAir ditching) nobody wants to mention the 'elephant in the room' - i.e. the bloody BOM??  

ATSB Safety Recommendation - R20000040 

Meteorological information


The Norfolk Island Meteorological Observing Office, which is staffed by four observers, normally operates every day from 0400 until 2400 Norfolk Island time. When one or more observers are on leave, the hours are reduced to 0700 until 2400 daily. Hourly surface observations by the observers, or by an automatic weather station when the office is unmanned, are transmitted to the Sydney Forecasting Office where they are used as the basis for the production and amendment of TAFs and other forecasts.

Weather conditions are assessed by instrument measurements, for example, wind strength, temperature and rainfall, or by visual observation when observers are on duty, for example, cloud cover and visibility. There is no weather-watch radar to allow the detection and tracking of showers, thunderstorms and frontal systems in the vicinity of the island. The wind-finding radar on Norfolk Island is used to track weather balloons to determine upper level winds six-hourly when observers are on duty. It cannot detect thunderstorms or rainshowers.

Pilots in the Norfolk Island area can contact the Met Office staff on a discrete frequency for information about the current weather conditions.

The reliability of meteorological forecasts is a factor in determining the fuel requirements. As forecasts cannot be 100% reliable, some additional fuel must be carried to cover deviations from forecast conditions.

A delay of one hour or more can exist between a change occurring in the weather conditions and advice of that change reaching a pilot. The change has to be detected by the observer or automatic weather station and the information passed to the Forecasting Office. After some analysis of the new information in conjunction with information from other sources, the forecaster may decide to amend the forecast. The new forecast is then issued to Airservices Australia and disseminated to the Air Traffic Services (ATS) staff who are in radio contact with the pilot. It is then the pilot's responsibility to request the latest forecast from ATS.


Alternate minima

Alternate minima are a set of cloud base and visibility conditions which are published for each airfield that has a published instrument approach procedure. The alternate minima are based on the minimum descent altitude and minimum visibility of each of the available instrument approaches. When the forecast or actual conditions at an airfield decrease below the alternate minima, aircraft flying to that airfield must either carry fuel for flight to an alternate airfield or fuel to allow the aircraft to remain airborne until the weather improves sufficiently for a safe landing to be conducted.

A pilot flying an aircraft that arrives at a destination without alternate or holding fuel and then finds that the weather is below landing and alternate minima is potentially in a hazardous situation. The options available are:

1. to hold until the weather improves; however, the fuel may be exhausted before the conditions improve sufficiently to enable a safe landing to be made;

2. to ditch or force-land the aircraft away from the aerodrome in a area of improved weather conditions, if one exists; or

3. attempt to land in poor weather conditions.

All of these options have an unacceptable level of risk for public transport operations.


The alternate minima for Norfolk Island are:

1. cloud base at or above 1,069 ft above mean sea level (AMSL) and visibility greater than 4.4 km for category A and B aircraft; and

2. cloud base at or above 1,169 ft AMSL and visibility greater than 6 km for category C aircraft.

The available alternate aerodromes for Norfolk Island are La Tontouta in Noumea (431 NM to the north), Lord Howe Island (484 NM to the south-west) and Auckland NZ (690 NM to the south-east). Lord Howe Island may not be suitable for many aircraft due to its short runway. Flight from Norfolk Island to an alternate aerodrome requires a large amount of fuel, which may not be carried unless required by forecast conditions or by regulations.


Australian regulations

Prior to 1991, the then Civil Aviation Authority published specific requirements for flights to island destinations. For example, flights to Lord Howe Island were required to carry fuel for flight to an alternate aerodrome on the mainland Australia, and flights to Norfolk Island and Cocos Island, where no alternate aerodromes were available, were required to carry a minimum of 2 hours of holding fuel.

In 1991, Civil Aviation Regulation (CAR) 234 was enacted. This regulation provided that an aircraft would not commence a flight unless the pilot in command and the operator had taken reasonable steps to ensure that the aircraft was carrying sufficient fuel and oil to enable the proposed flight to be undertaken in safety. The regulation did not specify the method for determining what was sufficient fuel in any particular case. Civil Aviation Advisory Publication (CAAP) 234-1(0) dated March 1991, provided guidelines which set out one method that could be used to calculate fuel requirements that would satisfy CAR 234. CAAP 234-1 did not contain any special considerations or requirements when planning a flight to an island destination.

In August 1999, Civil Aviation Order 82.0 was amended to require all charter passenger-carrying flights to Norfolk Island and other remote islands to carry fuel for the flight to their destination and to an alternate aerodrome. The alternate aerodrome must not be located on a remote island. This requirement to carry additional fuel does not apply to regular public transport flights to a remote island.


European Joint Aviation Regulation

The European Joint Aviation Regulation (Operations) 8.1.7.2 states: "at the planning stage, not all factors which could have an influence on the fuel used to the destination aerodrome can be foreseen. Consequently, contingency fuel is carried to compensate for ... deviations from forecast meteorological conditions."


Traffic levels

In February 2000, approximately 11 regular public transport aircraft land at Norfolk Island every week, including Boeing 737 and Fokker F100 aircraft. An additional 20 instrument flight rules and 12 visual flight rules flights are made to the island every week by a variety of business and general aviation aircraft.


ANALYSIS

Reports to the Bureau, including those detailed in the factual information section above, indicate that the actual weather conditions at Norfolk Island have not been reliably forecast on a number of occasions. Current regulations do not require pilots of regular public transport aircraft to carry fuel reserves other than those dictated by the forecast weather conditions. The safety consequences of an unforecast deterioration in the weather at an isolated aerodrome like Norfolk Island may be serious.

The present level of reliability of meteorological forecasts and the current regulatory requirements are not providing an adequate level of safety for passenger-carrying services to Norfolk Island.


SAFETY ACTION

As a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands.

Output text


The Australian Transport Safety Bureau (formerly the Bureau of Air Safety Investigation) recommends that the Bureau of Meteorology should review the methods used and resources allocated to forecasting at Norfolk Island with a view to making the forecasts more reliable.

Initial response


Date issued:
27 April 2000
Response from:
Bureau Of Meteorology
Action status:
Closed - Accepted
Response text:
In response to your letter of 25 February 2000 relating to Air Safety Recommendation 20000040 and the reliability of meteorological forecasts for Norfolk Island, the Bureau of Meteorology has explored a number of possible ways to increase the reliability of forecasts for flights to the Island.

There are several factors which determine the accuracy and reliability of the forecasts. The first is the quality and timeliness of the baseline observational data from Norfolk Island itself. The second is the information base (including both conventional surface observational data and information from meteorological satellites and other sources) in the larger Eastern Australia-Southwest Pacific region. The third is the overall scientific capability of the Bureau's forecast models and systems and, in particular, their skill in forecasting the behaviour of the highly localised influences which can impact on conditions on Norfolk Island. And the fourth relates to the speed and responsiveness with which critical information on changing weather conditions (forecast or observed) can be conveyed to those who need it for immediate decision making.

As you are aware, the Bureau commits significant resources to maintaining its observing program at Norfolk Island. While the primary purpose of those observations is to support the overall large-scale monitoring and modelling of meteorological conditions in the Western Pacific, and the operation of the observing station is funded by the Bureau on that basis, it is staffed by highly trained observers with long experience in support of aviation. As far as is possible with available staff numbers, the observers are rostered to cover arrivals of regular flights and rosters are adjusted to cover the arrival of notified delayed flights.

The Norfolk Island Terminal Aerodrome Forecast (TAF) is produced by experienced professional meteorologists located in the Bureau's New South Wales Regional Forecasting Centre in Sydney. The terminal forecast provides predictions of wind, visibility, cloud amount and base height and weather routinely every six hours. Weather conditions are continuously monitored and the terminal forecast is amended as necessary in line with air safety requirements. The forecasters have full access to all the Bureau's synoptic meteorological data for the region and guidance material from both Australian and overseas prediction models. As part of the forecasting process, they continuously monitor all available information from the region including the observational data from Norfolk Island itself. When consideration of the latest observational data in the context of the overall meteorological situations suggests the need to modify the terminal forecast, amendments are issued as quickly as possible.

Despite the best efforts of the Bureau's observing and forecasting staff, it is clear that it is not always possible to get vital information to the right place as quickly as it is needed and the inherent scientific complexity of weather forecasting means that occasional serious forecast errors will continue to be unavoidable. That said, the Bureau has carefully reviewed the Norfolk Island situation in order to find ways of improving the accuracy and reliability of its forecasts for aviation through a range of short and longer-term means.

As part of its strategic research effort in forecast improvement, the Bureau of Meteorology Research Centre is undertaking a number of projects aimed at increasing scientific knowledge specifically applied to the provision of aviation weather services. Research projects are focussed on the detection and prediction of fog and low cloud and are based on extensive research into the science of numerical weather prediction. However, with the current level of scientific knowledge, the terminal forecasts for Norfolk Island cannot be expected to be reliable 100 percent of the time. Based on figures available for the period January 1998 to March 2000 (some 12 000 forecast hours), the Bureau's TAF verification system shows that for category A and B aircraft when conditions were forecast to be above the minima, the probability of encountering adverse weather conditions at Norfolk Island airport was 0.6%.

As part of its investigations, the Bureau has considered the installation of a weather watch radar facility at Norfolk Island with remote access in the NSW Regional Forecast Centre. Although routine radar coverage would enable the early detection of precipitation in the vicinity of the Island, investigations suggest that the impact of the radar images in improving forecast accuracy would be on the time-scale of one to two hours. This time frame is outside the point of no return for current aircraft servicing the route. It was concluded that the installation of a weather watch radar would be relatively expensive and would only partially address the forecast deficiencies identified in Air Safety Recommendation R20000040. The Bureau will however keep this option under review.

To increase the responsiveness of the terminal forecasts to changes in conditions at Norfolk Island, the Bureau has issued instructions to observing staff to ensure forecasters at the Sydney RFC are notified directly by telephone of any discrepancies between the current forecast and actual conditions. This arrangement will increase the responsiveness of the system particularly during periods of fluctuating conditions. In addition the Bureau has provided the aerodrome manager with access to a display of the latest observations to ensure the most up to date information is relayed to aircraft.

The Bureau is actively participating in the review of fuel requirements for flights to remote islands being undertaken by the Civil Aviation Safety Authority.

I regret the delay in replying to your letter but the Bureau has felt it important to look carefully at all aspects of the Norfolk Island forecast situation and consider the full range of possibilities for forecast improvement within the resources available to us. We will continue to work on forecast improvement for Norfolk Island as resources permit

As you can see 15 years and very little has changed and the real culprit (latent safety risk) the BOM is yet to be effectively safety risk mitigated...FCOL

Final Q/ Why have the ATSB  or better still; why have the ATSB when we've got Dick Smith??

 
MTF...P2

[Gobbledock]

P2, thank you for your last post. A long but very succinct (and disturbing) post presented in a way that let's the viewer really see how the understanding of safety, risk, and hazard identification is not understood by at least two regional airports, CAsA, ASA and ATSBeaker.

And when I didn't think there could be anything more ludicrous than "Bill'duras" comments, along comes another airport backwater comment by another supposed airport guru;

"But airport manager Neil Weatherson said Ballina was one of the safest airports he has ever worked at.
"I'm not sure why it's become unsafe all of a sudden," he said.
"We've had a number of reports over the years from CASA (Civil Aviation Safety Authority) saying that there's no safety issue here".

Gotta love the bolded bit!! It's safe because CAsA said it is!! Neil, old mate, if that is what you base your safety comfort level on then I would suggest every commercial operator flying near, around, over or into Ballina should be shitting themselves! What world are these airports operating in? While planes are playing peekaboo in shite weather we have airport management sipping coffee and playing Charlie Charlie blissfully unaware of what is transpiring in the air above their airports (and their local suburbs).

So that is strike 2/2 for airports having no clue about safety methodology. Surely (and not that I want to) we can make it 3/3??
FFS boys, this shit is getting downright scary!

Yes P2, I totally agree mate........TICK TICK TICK TICK

[Kharon]

Rice bowl protection and abrogation of responsibility, writ large.

P2 – was the AWIS and NOTAM situation for Mildura ever fully examined?  Always made me smile, the notion that the automatic weather station was U/S.  Remember that part in estimates where there was lots of wriggling and squirming about who owned the unit, who owned the wires, who owned the weather data, who was responsible; hilarious.  Everyone was in Montreal or at the pub.

I’d place advance notice of actual conditions at a field on top of my list; QNH, cloud, wind and temperature/dewpoint; how many times have you called a CTAF and asked a local aircraft for the information? Makes life so much easier, but why is it that we have multiple redundancy and strict rules for airport lighting, navigation aid power,etc. dual everything just about on the flight deck – so that when an essential ‘item’ fails, the back up kicks in and we remain ‘safe’.  So why has a backup AWIS rule not been issued and why has the ATSB not taken direct action to ensure that whoever is responsible for making sure the vital terminal conditions are always available 24/7, irrespective, at every airport, not just NOTAMed as not being available. I reckon the Mildura crews would have said thank you for the advance ‘warning’; or a ‘chat’ with the friendly local fuel agent even.

[Peetwo]

Rice bowl protection and abrogation of responsibility, writ large.

Remember that part in estimates where there was lots of wriggling and squirming about who owned the unit, who owned the wires, who owned the weather data, who was responsible; hilarious.  Everyone was in Montreal or at the pub.

Here you go "K" for the record...

The Ferryman went onto say:

I’d place advance notice of actual conditions at a field on top of my list; QNH, cloud, wind and temperature/dewpoint; how many times have you called a CTAF and asked a local aircraft for the information? Makes life so much easier, but why is it that we have multiple redundancy and strict rules for airport lighting, navigation aid power,etc. dual everything just about on the flight deck – so that when an essential ‘item’ fails, the back up kicks in and we remain ‘safe’.  So why has a backup AWIS rule not been issued and why has the ATSB not taken direct action to ensure that whoever is responsible for making sure the vital terminal conditions are always available 24/7, irrespective, at every airport, not just NOTAMed as not being available. I reckon the Mildura crews would have said thank you for the advance ‘warning’; or a ‘chat’ with the friendly local fuel agent even.

Sounds fairly reasonable and in the US - at least - the 'regulated' UNICOM system is a relatively cheap 'safety risk' mitigation alternative for popular OCTA GA aerodromes/airports.

Poster mjbow2 - from off the UP - took Capn Bloggs to task.. ..while at the same time properly explaining the advantages of the US UNICOM system:

Quote: "..do you really think you'd have one of your "existing" staff at the airport with enough spare time to monitor and provide the weather, let alone a traffic service?.."


Absolute crap Bloggs. Every RPT airport you fly to Bloggs, you radio your company personnel on the ground with an ETA and they tell you what bay to park on.

Your company personnel are already monitoring a radio and are already at the airport 'floating around' as you say, ready to talk to you on the radio, but suddenly if they were allowed to provide you with an airport advisory at the same time it becomes too onerous on them?

If your company reps were able to monitor the CTAF frequency and provide a Unicom service to those aircraft that request an advisory (Hint... thats you Bloggs in your 717) then safety is enhanced. So simple.

Quote: "..let alone a traffic service? .."

Contrary to what you think the service is supposed to do, it does not provide Air Traffic Control functions AT ALL. Do you understand this?

You try and tear down this simple well proven affordable measure with the most specious arguments that only goes to prove that your ignorance of how its done elsewhere and a pathological resistance makes you look foolish.

Whatever you think you know about how a Unicom service should work is just plain wrong. Its sad to think that younger pilots may give credence to your remarks merely because you fly a jet.

The FAA also doesn't agree with your assessment that Unicom services are "not going to wash". You might wish to familiarise yourself with Ops Spec C064 and C080 (a) 2. These require On Demand passenger, All Cargo and scheduled airline operations to be able to acquire "traffic advisories and the status of airport services and facilities" at uncontrolled airfields.

The Unicom is required by the regulations in the United States to enhance safety at uncontrolled airports.

Yes the person providing information might be the check in staff, it might be the fueler at the FBO or the mechanic at the local maintenance workshop but the total cost is the price of the radio itself. A very cheap safety measure.

No one is providing a directed traffic service or even a traffic information service. If the person talking on the radio on the ground is asked for an 'airport advisory' it is as simple as this;

Wind
Temperature
Visibility
Cloud ceiling
light aircraft heard in the vacinity/ Helicopter transiting area/
maintenance vehicle operating on taxiway
etc.

The Unicom operator does not need to know where other traffic is in the area. In fact as radio is not mandated for aircraft at uncontrolled airports in the US, its possible that the Unicom operator does not know where aircraft might be positioned. NO PROBLEM, the operator just alerts arriving and departing aircraft of other aircraft in the vicinity IF they know they are about. Otherwise the operator simply says 'no known' traffic or omits any reference to traffic in their advisory.

Simple, easy safety related information given via a Unicom service mandated by the regulations. Not an ATC function. Is this easy for you to understand Bloggs? We too should have this virtually free service right here in Oz.

That last part in bold.. "Not an ATC function"..is perhaps where CASA went wrong when UNICOM was first mooted as part of a PIR recommendation of NAS2c (see here)...

CASA should encourage the provision of UNICOM services, with

approval to issue traffic advisories, be further encouraged and a

competency based standard for UNICOM operators and CA/GRS

be developed.

Basically they over-complicated things and put the UNICOM concept in the hands of ASA, who - in partnership with CASA - were always going to make it overly regulated (& therefore cost prohibitive) because they were shit scared of liability...

But back to the overly prolonged ATSB Mildura fog incident investigation, the following was extracted from the bureau's 2013-14 Annual report (released October 2014):

Other aviation investigations that raised significant issues about safety


Other aviation investigations conducted during the financial year that the Chief Commissioner considers raise significant issues about safety include a weather-related operational event and the in-flight break-up of a PZL Mielec M18A Dromader agricultural aircraft during firebombing. These investigations are discussed in the following sections.

Weather-related operational event involving B737s, registered VH-YIR and VH-VYK, at Mildura Airport, Victoria on 18 June 2013

On the morning of 18 June 2013, a Boeing 737 aircraft, registered VH-YIR and operated by Virgin Australia, was conducting a scheduled passenger service from Brisbane, Queensland to Adelaide, South Australia. On board were six crew members and 85 passengers.

On the same morning, another B737 aircraft, registered VH-VYK and operated by Qantas Airways, was conducting a scheduled passenger service from Sydney, New South Wales, to Adelaide, South Australia. On board were six crew and 146 passengers.

Due to poor weather in Adelaide, both aircraft were forced to divert to an alternate airport (Mildura, Victoria). This airport was also affected by unforecast poor weather (fog) at the time of their arrival. Both aircraft landed safely, but not without difficulty for their crews.

The ATSB commenced an investigation to examine:

• the provision of information to flight crews from air traffic services (ATS)
  
• ATS policies and procedures affecting the flights
  
• provision by the operators of information to the respective flight crews
  
• the basis for the sequencing of the aircraft landings at Mildura
  
• Bureau of Meteorology meteorological services and products as they applied to these flights
  
• the accuracy of aviation meteorological products in Australia.
  
  

As part of this investigation, the ATSB convened a safety forum on 31 March 2014 involving a number of industry participants. The forum identified several issues, most of which are pertinent to this occurrence, and more widely across the aviation industry.
These included:

• differing levels of expectation in relation to the provision of amended meteorological products
  
• inconsistencies in standard aviation reference documentation in relation to the use of meteorological products
  
• differing levels of understanding and awareness of the availability of meteorological products, including limitations relating to automated weather broadcast systems
  
• the effect of international obligations and restrictions on the provision to flight crews of updated weather information
  
• limitations associated with the staged introduction of new technologies
  
• the need for a coordinated education program to update and deconstruct many long held beliefs and misconceptions within the aviation industry.
  
  

The investigation is continuing, with the majority of the initial evidence collection complete. In addition to its analysis of this initial evidence, the ATSB continues to work with sections of the aviation industry to enhance its understanding of the issues that were identified at the safety forum, and to identify any safety issues.

In addition, as a result of this and other occurrences involving observed but not forecast
weather, the ATSB has commenced supporting research investigation AR-2013-200
Reliability of aviation weather forecasts. This research investigation will analyse Bureau
of Meteorology data across Australian airports, with a focus on those supporting scheduled passenger service operations, and is subject to the availability of long-term data holdings of aviation forecasts and observations.

The research investigation is also continuing, and will:

• examine the accuracy of aviation meteorological products in Australia
  
• examine the procedures used to provide information to flight crews from air traffic services, and management of changes to those procedures
  
• examine the provision by the operators of information to the respective flight crews
  
• examine the relevant recorded data
  
• review the distribution, dissemination and sharing of operational information to the aviation industry as stipulated by the Civil Aviation Safety Authority, and enacted by Airservices Australia and the Bureau of Meteorology.
  

  
So from Dolan's point of view the Mildura incident raises 'significant issues' but not 'significant safety issues' worthy of publishing - or promulgating as an SR - to the greater industry at large...UFB  

MTF...P2  

Ps For Dick's benefit the 2008 UNICOM exemption - CASA EX40/08 - signed by Bruce Byron, in Sched 1 included Hervey Bay:
   

Schedule 1 - Aerodromes

             Dubbo, Hervey Bay, Olympic Dam, Port Macquarie, Wagga Wagga.

  
Update: From the Weekend Oz - [b]Pilots forced to weather cloudy service  [/b] 

[Kharon]

The four horsemen of the aviation Apocalypse.

Thank you P2, much obliged.

Responsibility, accountability, liability and who pays.   The FAA managed, in one the most litigious countries on the planet (after Australia) to not only see off these bogey-men, get it sorted out, but also enshrined it in simple clear law.  Aye well, at least we can still drink the water.  As mjbow2 quite properly remarks company frequency is almost a must have, particularly at FIFO destinations and support airfields, so a small extension as suggested and mandated in the US of A would, you’d think be welcome down under.    

QoM UP candidate  Mjbow2 –

“You try and tear down this simple well proven affordable measure with the most specious arguments that only goes to prove that your ignorance of how its done elsewhere and a pathological resistance makes you look foolish.

Bit harsh singling out Bloggs though, he is simply representative of the hind bound, rule loving, pedantic, constipated, unionised, smug, self satisfied herd of Australian lovers of black letter law, terminal arrogance and colloquial ignorance.   Not really his fault, is it?

Toot toot… ....

[Peetwo]

Has been a bit quiet on here of late, however with a couple of significant heavy tin investigation final reports being released by the ATSB, & causing much discussion in various forums,...

Examples from PT -  Virgin Australia gets wake up call over botched Melbourne 777 approach   or; Qantas acts over too low approach by A330 to Melbourne

...I thought now might be a good opportunity to liven things up...

So here are the links for the 2 completed ATSB investigations currently under discussion:

Investigation number: AO-2013-047

Investigation status: Completed
 

• Summary
  
• Photo
  
• Safety Issue
  

Download final report
[PDF: 1.69MB]
  
Alternate: [DOCX: 1.47MB] 

[*]Investigation number: AO-2013-130

Investigation status: Completed
 

• Summary
  
• Photos
  
• Safety Issue
  

[*]
Download final report
[PDF: 1.7MB]
 
 Alternate: [DOCX: 1.32MB]

[*]
The Qantas A330 incident was opened up to discussion in the P7 thread - ATSB - Qantas Melbourne. However with the release yesterday of the ATSB Virgin YMML incident final report -  even though very much related - the discussion has diverged slightly away from the analysis of the actual ATSB final reports.

So here is where we ended up when looking at the probable causal chain (contributory factors) in regards to the breakdown of situational awareness in the Qantas A330 incident:

...Okay now a bit of historical relevance and in the aftermath of the Lockhart River tragedy the ATSB of old took on-board some of the findings from their investigation and decided to conduct a research project that was coupled with a survey of 748 GA IFR pilots endorsed on the RNAV (GNSS) approach.

Here is the abstract of that report, from that man again Dr Stuart Godley:

Abstract

Area navigation global navigation satellite system (RNAV (GNSS)) approaches have been used in Australia since 1998 and have now become a common non-precision approach. Since their inception, however, there has been minimal research of pilot performance during normal operations outside of the high capacity airline environment. Three thousand five hundred Australian pilots with an RNAV (GNSS) endorsement were mailed a questionnaire asking them to rate their perceived workload, situational awareness, chart interpretability, and safety on a number of different approach types. Further questions asked pilots to outline the specific aspects of the RNAV (GNSS) approach that affected these assessments. Responses were received from 748 pilots, and answers were analysed based on the aircraft performance category1. For pilots operating Category A and Category B aircraft (predominantly single and twin-engine propeller aircraft), the RNAV (GNSS) approach resulted in the highest perceived pilot workload (mental and perceptual workload, physical workload, and time pressure), more common losses of situational awareness, and the lowest perceived safety compared with all other approaches evaluated, apart from the NDB approach. For pilots operating Category C aircraft (predominantly high capacity jet airliners), the RNAV (GNSS) approach only presented higher perceived pilot workload and less perceived safety than the precision ILS approach and visual day approach but lower workload and higher safety than the other approaches evaluated. The different aircraft category responses were likely to have been due to high capacity aircraft having advanced automation capabilities and operating mostly in controlled airspace. The concern most respondents had regarding the design of RNAV (GNSS) approaches was that they did not use references for distance to the missed approach point on the approach chart and cockpit displays. Other problems raised were short and irregular segment distances and multiple minimum segment altitude steps, that the RNAV (GNSS) approach chart was the most difficult chart to interpret, and that five letter long waypoint names differing only by the last letter can easily be misread.

   
Now if you cut to the business end of the Godley report you will see that their was several Safety Recommendations that were promulgated due to the findings of that report:

7.4 Recommendations

Recommendation R20060019

Safety issue: RNAV (GNSS) approach pilot workload and situational awareness
Pilot workload was perceived as being higher, and reported losses of situational
awareness were reported as more common, for the area navigation global navigation
satellite system (RNAV (GNSS)) approach than all other approaches except the nondirectional beacon (NDB) approach, which involved similar workload and situational
awareness levels.

This was especially a concern for pilots operating Category A and Category B
aircraft. Further research into pilot workload and losses of situational awareness
associated with RNAV (GNSS) approaches is warranted.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority address this safety issue.

Recommendation R20060020

Safety issue: RNAV (GNSS) approach chart design and interpretability
The most common concern identified by respondents about the design of RNAV
(GNSS) approaches was that the charts did not use references for distance to the
missed approach point throughout the approach on the global positioning system
(GPS) or flight management system (FMS) displays, and distance references on the
approach charts were inadequate. Approach chart interpretability was assessed as
more difficult for the RNAV (GNSS) approach than all other approaches by
respondents from all aircraft performance categories. Respondents considered that
the information presented on RNAV (GNSS) approach charts, including distance
information, may not be presented in the most usable way, and consequently may
lead to loss of situational awareness.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060021

Safety issue: Sub-optimal RNAV (GNSS) approach design
The 21.5% of Australian area navigation global navigation satellite system (RNAV
(GNSS)) approaches deviates from the optimum design parameters (short and
irregular segments less than 5 NM and/or multiple steps within segments, and/or
multiple minimum segment altitude steps) particularly approaches in the vicinity of
high terrain. This was identified as a major concern by many pilots. A review to
determine whether designs closer to the optimum approach profile could be
developed, within the ICAO Pans-Ops limitations, was considered appropriate.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060022

Safety issue: RNAV (GNSS) approach chart waypoint naming convention
The naming convention of using five capital letters for waypoint names, with only
the final letter differing to identify each segment of the approach, was reported to
cause clutter on the charts and GPS and FMS displays, and also increase the chance
of a pilot misinterpreting a waypoint. This can lead to a loss of situational awareness.
With the growing body of international experience using RNAV (GNSS) approaches,
it may be timely to review the naming convention.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060023

Safety issue: RNAV (GNSS) approach late notice of air traffic control clearance
Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach
was identified as the most common difficult external condition affecting an RNAV
(GNSS) approach, particularly for high capacity airline pilots. An examination of
opportunities to improve training and/or procedures for air traffic controllers to help
ensure timely approach clearances is warranted.

The Australian Transport Safety Bureau recommends that Airservices Australia, in
conjunction with the Civil Aviation Safety Authority, address this safety issue.

Recommendation R20060024

Safety issue: RNAV (GNSS) approach late notice of air traffic control clearance
Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach
was identified as the most common difficult external condition affecting an RNAV
(GNSS) approach, particularly for high capacity airline pilots. An examination of
opportunities to improve training and/or procedures for pilots to help ensure timely
approach clearances is warranted.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority, in conjunction with Airservices Australia, address this safety issue.

If you follow the SR links provided and read the responses etc. ; you can make up your own mind on the following questions.

 Q1) Were the Safety Recommendations proactively acted on?; & if so Q2) were the identified significant safety issues appropriately risk mitigated?

Now at no time do I suggest that the design, of either the STAR or the RNAV (GNSS approaches) is the primary cause for the breakdown of SA in any of these incidents/accidents. However I do believe there is a common theme here, that coupled with other factors like pilot fatigue, breakdown of CRM etc. could be one of the holes in Reason's Swiss cheese model.  

[*]{Comment: One of the points of contention with the two reports yesterday - which IMO also goes to probity - was Ben Sandilands discovery that the Virgin Investigation was not classified as 'serious' whereas the Qantas investigation was?? See here -  ATSB tweets that Qantas Melbourne incident was an accident that nearly happened }

[*]Ok finally here is an extremely relevant comment from the Ferryman posted this AM on the PT blog:

[*] Sam Jackson
Posted July 16, 2015 at 9:13 am | Permalink

777 Steve – agreed, but there’s more, much more which could be added to all the incidents, those which have been glossed and polished to a fare-thee-well. The ‘system’ is collapsing around our ears. Perhaps someone could fetch DPM Truss a fiddle to play while Rome burns. That would at least entertain us.

NZGhost, the CVR data is not really available; not without a gabfest and hoops; a transcript may be provided in the final report, sometime in the future. Any and all of these increasing incidents could, with very trouble or expense be simulated. It’s pretty routine to revisit (time permitting) an incident scenario; most instructive. The tape I would most like you to hear is any one night’s peak hour approach control radio traffic for Tulla; it’s not for the feint hearted.

But we must be thankful for small mercies; at least the Essendon- Tulla comms link was working, I’d hate to think what may have happened, if the VA low pass event transpired during another three hour ‘breakdown’ of service. No worries we’ll always have the “poster’ depicting the ASA vision splendid; all we now need is courage badges, for all.

[*]
[*]
  
Much MTF..P2

[Kharon]

Probity - deemed non essential.

I believe it must be said that in the search for investigative purity; both Qantas and Virgin would have achieved that in their own investigations.  They take risk mitigation seriously and their management teams which would look, very closely, at all the data would have discovered exactly what happened, worked out how to correct things; and, minimised the risk of an other similar occurrence.  Even if it was just to issue an advisory, they don’t mess about.  JHBC, Can you imagine what would happen if a Qantas (or VA) team took a full 24 months and produced an internal report, like the ATSB ‘thing’.  There’d be, metaphorically, bodies everywhere.  Only a government agency can squander time, money and talent like that – and get away with it.

That professionalism and speedy resolution could, I suppose, be parlayed into a reason why the ATSB did such a poor job of reporting the incidents.  It’s a lazy, cynical, cost effective way to keep the budget plump, piggy back on industry expertise to claim the glory, keep looking good and fool the people.  The airlines would have these mishaps spanked into shape before Beaker could find his boots under the bed.  Neither airline has a need to puff out it’s chest and tell anyone about their cure for the problems; no need to wait two years for the Beaker summary version; they’d have it fixed and forgotten a month after it happened.  

But, it begs the question, do we need ATSB at all?  They can’t or won’t investigate ‘GA’ incidents; they don’t really have to investigate ‘Big iron’ incidents; (chuckle), even if they did, the airline boys would tell ‘em to bugger off (unless there was a liability issue).  So what purpose do they serve, producing reports that help no one, two years after an event.

Even when they get a decent report, like the one young Doc Godley provided (above) into the perils of GNSS, what? 10 years ago, about which they have done sod all.  Godley is clearly and intelligent man, his research was painstaking, the conclusions not only accurate, but proven correct.  Money well spent I’d say until you realise, it was wasted.  The report was, to all intents and purpose ‘shelved’ and ignored; same as the Senate, Forsyth and TSBC reports.  

Meanwhile, we have the Beaker Blog which serves to amuse many and gives his Mum something to do between episodes of Judge Judy and Dr Phil (never be at home with a sick woman, it’s TV misery all bloody day; and, the cricket is verbotten).

Aye, but before we take a close look at the latest from the Beaker dreamtime, sheltered workshop in full technicolour, consider this – by the time we get the report – FWIW – the pro’s have fixed it or patched it, because, believe it not, aircraft and flight crew work 24/7; they do, and they need real answers, in real time, lest someone gets hurt.  They have no time to hang about waiting for the Beyond All Reason methodolanology to provide a nonsense; they are far to concerned with closing loops and risk mitigation. 

We shall however humour our dear P2 and look through the ATSB twiddles, perhaps ATSB have discovered something the safety professionals missed; but I doubt it. 

I hear Alan Strange has changed his name to Roly-Poly Strange, in preparation for rolling about in his grave.  Lord he must be spitting chips (and probably a bit of fish too).

That’s it – time for a cold one or two; maybe three; if I get away with it.

Toot toot....

[Gobbledock]

'K';

"So what purpose do they serve, producing reports that help no one, two years after an event".

My dear Ferryman, you are asleep at the Houseboat wheel and have not seen things clearly (fatigue perhaps or poor pilot eyesight?) you need to think outside the box. Beakers reports serve a multitude of purposes, and in true Gobbledock style, here are just a few;

- The ATsB reports make great masturbation fodder for Lookleft
- The reports provide a rather 'clean wipe' when one is defecating
- The reports are an excellent 'learning tool' for 'how not to write a report lessons' being delivered to third world agencies as part of their training
- The reports make good cage floor lining in bird aviaries
- The reports really connect with the reader and are succinctly understood - by my Grandchildren aged 5 and 8 (they really enjoy it when the bald man with a beard reads the reports out loud and starts bobbing his head and mi mi mi-ing!)

Beaker Beaker Beaker, what can I say but cue the flush button!

P_666

It's a big, dirty job.  Our hero uses a Muppet, grab by the ankles, place the head in the hole  and brush vigorously.  Yuk, yuk, Yak.  ("K").

[Kharon]

Analysis – deemed non essential.

The 777 event is deemed ‘an incident’.  The A330 event is defined as a 'serious' incident.
There’s a head scratcher for starters.  I expect the difference is because the EPGWS chimed in.  But it’s the ‘result’ section of both ‘summary’ reports that makes me despair of ATSB.

Q - In response to this occurrence Qantas updated their training material for visual approaches and enhanced similar material in their captain/first officer conversion/promotion training books. In addition, targeted questions were developed that required check pilot sign off for proficiency. Finally, visual approaches were included as a discussion subject during flight crew route checks for the period 2013–2015.

The ATSB “Safety message” cracks me up; Qantas have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.  

VA - The ATSB has been advised by Virgin Australia International Airlines that the SHEED approach is no longer available for use by its Boeing 777 crews.

The ATSB “Safety message” cracks me up; VA have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.

But I like the VA response, cut and dried, don’t use that approach.  It is at least succinct, does it address the deeper implications?  We’ll never know, VA sorted it out, internally and once again without any need for ATSB or CASA assistance.  

Q - Incident March 2013; report release June 2015.   ATSB, two years + a bit to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion. 

V - Incident Aug 2013; report release June 2015.   ATSB just a shade under  two years to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion.

ATSB were superfluous, not required in either incident.  Both matters were resolved in house, by experts, at a pace in keeping with the needs of the airline to keep operating.  No one engaged in real world, real time operations can be ducking about, waiting 24 months for a ‘safety’ analysis ; they have to crack on.

The point I’m struggling to make is that both incidents were, potentially serious accidents.  The airlines involved moved swiftly, positively and effectively to mitigate the immediate risk.  Bravo, well done, but no more than we could reasonably expect from first class air carriers.  The ATSB didn’t help too much, nor did the complex 'safety' regulations, or those who wrote them.

Where ATSB fail miserably is in the area where one could reasonably the ATSB to be of real value for money.  There are some deep, esoteric and subtle elements in the ‘chain’ of events leading up to the incidents; these have not been analysed, therefore there is no ‘deep and meaningful’ academic assessment of the peripherals, which may have assisted either airline to ‘modify’ their thinking.  There is nothing published which may assist the ASA to modify their thinking and perhaps make some changes to the Melbourne terminal airspace.  After a two year study, costing gods only know what, I’d have expected something adding value.  It’s a pity the airlines can’t publish their reports; they may be worth reading.

In short Minister, we got ripped off - again.  

Toot toot.  

[Peetwo]

Analysis – deemed non essential.

The 777 event is deemed ‘an incident’.  The A330 event is defined as a 'serious' incident.
There’s a head scratcher for starters.  I expect the difference is because the EPGWS chimed in.  But it’s the ‘result’ section of both ‘summary’ reports that makes me despair of ATSB.

Q - In response to this occurrence Qantas updated their training material for visual approaches and enhanced similar material in their captain/first officer conversion/promotion training books. In addition, targeted questions were developed that required check pilot sign off for proficiency. Finally, visual approaches were included as a discussion subject during flight crew route checks for the period 2013–2015.

The ATSB “Safety message” cracks me up; Qantas have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.  

VA - The ATSB has been advised by Virgin Australia International Airlines that the SHEED approach is no longer available for use by its Boeing 777 crews.

The ATSB “Safety message” cracks me up; VA have done all the heavy lifting, fixed up as best they can the result of the duck up; and taken steps to prevent a reoccurrence.  ATSB just point out the blindingly obvious, then call it a ‘complex’ investigation and publicly claim it as ‘their’ fix.

But I like the VA response, cut and dried, don’t use that approach.  It is at least succinct, does it address the deeper implications?  We’ll never know, VA sorted it out, internally and once again without any need for ATSB or CASA assistance.  

Q - Incident March 2013; report release June 2015.   ATSB, two years + a bit to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion. 

V - Incident Aug 2013; report release June 2015.   ATSB just a shade under  two years to arrive at a non conclusion, state the blindingly obvious and contribute nothing of any value to the discussion.

ATSB were superfluous, not required in either incident.  Both matters were resolved in house, by experts, at a pace in keeping with the needs of the airline to keep operating.  No one engaged in real world, real time operations can be ducking about, waiting 24 months for a ‘safety’ analysis ; they have to crack on.

The point I’m struggling to make is that both incidents were, potentially serious accidents.  The airlines involved moved swiftly, positively and effectively to mitigate the immediate risk.  Bravo, well done, but no more than we could reasonably expect from first class air carriers.  The ATSB didn’t help too much, nor did the complex 'safety' regulations, or those who wrote them.

Where ATSB fail miserably is in the area where one could reasonably the ATSB to be of real value for money.  There are some deep, esoteric and subtle elements in the ‘chain’ of events leading up to the incidents; these have not been analysed, therefore there is no ‘deep and meaningful’ academic assessment of the peripherals, which may have assisted either airline to ‘modify’ their thinking.  There is nothing published which may assist the ASA to modify their thinking and perhaps make some changes to the Melbourne terminal airspace.  After a two year study, costing gods only know what, I’d have expected something adding value.  It’s a pity the airlines can’t publish their reports; they may be worth reading.

In short Minister, we got ripped off - again.  

Toot toot.  

...& Minister while your there, could you please tell the Muppet to publish your SOE...FCOL

Hey "K" choc frog post that one..

Just to help you out mate, here are the two farcical safety issues that are published on the non-user friendly bureau website - gotta say why do they bother :

Guidance material


Issue number: AO-2013-130-SI-01

Who it affects: Virgin Australia International Airlines B777 pilots

Issue owner: Virgin Australia International Airlines

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-130

Date: 15 July 2015

Safety issue description

The presentation of the runway 34 visual approach in the operator's Route and Airport Information Manual increased the risk of the runway threshold crossing altitude being entered into the runway extension waypoint.

Proactive Action

Action Organisation: Virgin Australia International Airlines

Action number: AO-2013-130-NSA-031

Date: 15 July 2015

Action status: Closed

Virgin Australia International Airlines has advised that the SHEED approach to runway 34 at Melbourne is no longer to be used by its Boeing 777 crews. 
 
Current issue status:
Adequately addressed

Status justification:
The action by Virgin Australia International Airlines eliminates the risk associated with the safety issue.
 

Visual approach guidance


Issue number: AO-2013-047-SI-01

Who it affects: Flight crew

Issue owner: Qantas

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-047

Date: 09 July 2015

Safety issue description
Qantas provided limited guidance on the conduct of a visual approach and the associated briefing required to enable the flight crew to have a shared understanding of the intended approach.

Proactive Action

Action organisation: Qantas

Action number: AO-2013-047-NSA-032

Date: 09 July 2015

Action status: Closed

Qantas advised that in response to this occurrence they:

Updated the material for visual approaches in their flight training library.

Enhanced the material for visual approaches in the captain and first officer conversion/promotion training books including targeted questions that required check pilot sign off for proficiency.

Added visual approaches as a subject for discussion during flight crew route checks for 2013/2014 and 2015.
 
 
Current issue status:
Adequately addressed

Status justification:
The ATSB is satisfied that the safety action adequately addresses this safety issue.
 

Ok all good, nothing to see or learn from here, move along & Beakers BASR ("Beyond All Sensible Reason") methodology strikes again - please can someone save our bureau from this muppet??

The following quotes/excerpts are taken from the AIPA submission 8 to the Pel-Air cover-up Senate Inquiry.  A submission I might add that is well worth taking the time to read in it's entirety 

First this on the standards of the ATSB reports:

From bottom of page 8: ...In 2011, we raised our concerns in our Supplementary Submission to this Committee during the Inquiry into Pilot Training and Airline Safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 in this way:

“Are ATSB Reports serving their intended safety purpose or are they too late and too superficial to be anything other than records of bureaucratic activity?
AIPA is of the view that recent major reports are not serving their safety improvement purpose due to a lack of depth, particularly in regard to HF, and a lack of timeliness. We believe that, without the technical and HF insight that is required for complete understanding of complex failures, it is difficult to defend against an inaccurately or inadequately described problem.

Similarly, if nobody really remembers the problem or they think it has already been solved before a report is issued several years after the event, then the report has lost its value (other than a record of activity). The roadblocks to timely publication must be eliminated.

AIPA believes that there needs to be a formal system for multilateral industry assistance to the ATSB to supplement its resources, particularly in regard to specialist operational and technical knowledge.”16

It is through that prism that AIPA provides its comments....

Then on the ATSB BASR approach to identified safety issues & safety recommendations:








Finally the following quote from AIPA's ASRR submission perhaps highlights the view of many of Qantas pilot's (at least) in regards to having & maintaining a fully independent State AAI:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was
being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety.

Current knowledge, post the Senate Inquiry, suggests not.

AIPA believes that the ATSB has a very clear duty under the TSIA to independently and
holistically examine the aviation safety system. Pandering to the ego or behaviour of any
stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.

Recommendation 3


AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

Hmm...no further comment required, except to say...."Dear Minister, READ & ABSORB"

MTF...P2

[Kharon]

DAS'd hopes.

It is most satisfactory when a respected group, like AIPA weigh in and support the IOS claims.  It’s not too bad when a piece of PAIN research is picked up and expanded either; but the icing on the cake is that both reports were looked at by the Committee in relation to the Pel-Air scandal.  

PAIN, AIPA and many others were in concert during the Forsyth review.  All top class stuff; wasted thus far.  I know how much effort and research went into the PAIN submissions and can, with a little effort work out the equation for the AIPA effort.  When you add it all up; and include the many other fine submissions to both inquiries; it is a no brainer to see that there is a serious outcry from many people, against the incompetence and intransigence of CASA, ATSB and to some degree ASA and the BoM.  

It’s a mess – it needs to get cleaned up – it’s not getting done.

We hear DPM Truss wants it done; we hear Boyd &Co want it done; we hear the Rev Forsyth wants it done, we know industry want it done.  So what’s the ducking hold up?

It’s all there; easily discernible from industry submission; concise, verifiable, honest, expert opinion; freely offered, in hope of reform.  Instead, we get Skidmore, part 61, part 135 to come and CAO 48.1, as a reward for that effort.   It’s a Bollocks. 

Selah.

[Peetwo]

The following quotes/excerpts are taken from the AIPA submission 8 to the Pel-Air cover-up Senate Inquiry.  A submission I might add that is well worth taking the time to read in it's entirety 

First this on the standards of the ATSB reports:

From bottom of page 8: ...In 2011, we raised our concerns in our Supplementary Submission to this Committee during the Inquiry into Pilot Training and Airline Safety including consideration of the Transport Safety Investigation Amendment (Incident Reports) Bill 2010 in this way:

“Are ATSB Reports serving their intended safety purpose or are they too late and too superficial to be anything other than records of bureaucratic activity?
AIPA is of the view that recent major reports are not serving their safety improvement purpose due to a lack of depth, particularly in regard to HF, and a lack of timeliness. We believe that, without the technical and HF insight that is required for complete understanding of complex failures, it is difficult to defend against an inaccurately or inadequately described problem.

Similarly, if nobody really remembers the problem or they think it has already been solved before a report is issued several years after the event, then the report has lost its value (other than a record of activity). The roadblocks to timely publication must be eliminated.

AIPA believes that there needs to be a formal system for multilateral industry assistance to the ATSB to supplement its resources, particularly in regard to specialist operational and technical knowledge.”16

It is through that prism that AIPA provides its comments....

Then on the ATSB BASR approach to identified safety issues & safety recommendations:







Finally the following quote from AIPA's ASRR submission perhaps highlights the view of many of Qantas pilot's (at least) in regards to having & maintaining a fully independent State AAI:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety.

Current knowledge, post the Senate Inquiry, suggests not.

AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.

Recommendation 3

AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

Addendum - DAS'd hopes.

The following is a link for the PAIN research & opinion piece - Opinion :-ATSB since 2003. In the course of the Senate AAI Inquiry this paper was submitted to the RRAT References Committee for their review.

The part to which AIPA reference in their submission 8 to the Committee is on pages 4 & 5.

From page 5 of PAIN report:

Opinion: This data clearly shows the demise of the Safety Recommendation in Australia but it does not mirror the ‘tremendous’ savings made by not having to administer such an essential database. Which seems to be Mr Dolan’s primary focus.

What the data also clearly shows is that the leading transport investigation authority the NTSB do not share the ATSB philosophy on the issuing of safety recommendations. The
NTSB know that safety recommendations are indeed the cornerstone of their existence and the safety information contained within recommendations will be disseminated across the aviation industry, the travelling public and indeed around the world.

The following is an excerpt of the generic ‘Safety Action’ statement issued with nearly all
ATSB Final Reports within the last two years:

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

Opinion: Translated this means is that unless an interested party actually reads the report the safety action information contained within the report is effectively ‘invisible’ and will not be disseminated across worldwide industry stakeholders.

Generating Safety Recommendations ensures that the safety action information is totally
transparent.

PAIN has several substantial volumes of information that show the demise of the ‘Safety
Recommendation’ in Australia, such is our concern on this issue.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island
and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they
provide further examples of compromised ATSB Final Reports.

Also relevant to the discussion is PAIN supplementary submission (click on title) - NGA_Senate_Supplement.pdf - to which Chapter 7 is of particular relevance.

MTF..P2

[Peetwo]

From AIPA ASRR submission:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety.

Current knowledge, post the Senate Inquiry, suggests not.

"..AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.."

Recommendation 3

AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

 
Sadly the AIPA message (large & in bold), along with Recommendation 3 seem to have been totally & utterly ignored by the 'powers to be', while the ATSB continues to play lapdog to 'other' government agencies and to be 'captured' by certain 'other' industry stakeholders.

A clear example of this embuggerance of the bureau is perfectly highlighted in my post - ATSB v NTSB: A point of comparison.  However that is IMO merely the tip of the iceberg.

In the process of putting together that post, I was searching for the interim report from the Virgin investigation AO-2013-130, to which Marty Khoury referenced in his excellent blog post. From that it would seem that the ATSB are now in the habit of deleting all records of updates to an investigation and any previous links for prelim, interim etc. reports. This apparent change in protocol/methodology is only a recent development.

Example from the MK blog post there were some comments from Ben & MK. And in those comments MK transposed a couple of screenshots from the ATSB investigation page. The last post (update) was June 3, 2015 but you will see that from the ATSB AO-2013-100 - that like the links for the prelim & interim reports - those updates also no longer exist.

Marty
Author
June 3, 2015 at 8:42 am - Reply

Waiting…

As I mentioned earlier the Virgin investigation is not an isolated aberration, you only need to go down the ATSB  aviation Investigation index page & click on any number of  'Final' reports completed, including the Qantas YMML A330 incident report. It is not until about page two with the Bulli Tops R44 FR that there is a record of a prelim report (http://atsb.gov.au/publications/investig...3-055.aspx)

Which in itself is interesting because that report was coupled with the issuing of SRs to international parties - see here - & therefore the only report likely to garner any significant international interest.

What does this mean? Well maybe not much because under the TSI Act it would seem that the ATSB is not obliged to publish interim/prelim reports etc. However, as we know, it is a very different matter when it comes to the ICAO SARPs.

It is also worth noting that - as far as I am aware - interim & prelim (in the ATSB system) reports are not normally subject to review from the Commissioners, it is only after the DIP process that the Commissioners review the DRAFT FR. This means that the Virgin Interim report where MK referenced & then stated...

Stabilised Approaches

From the ATSB report:

   Quote: Wrote:The aircraft was levelled off at about 700 ft above mean sea level (AMSL), or about 500 ft above ground level, and turned to the right to align with the runway.

The incorrect FMC programming is a mistake not that dissimilar to low risk errors made virtually every day at every airport around the globe. In almost all circumstances, a correction is quickly applied without any consideration or thought and a normal approach and landing is continued. What concerned me about the incident in Melbourne – which wasn’t asked of the ATSB in their interim summary nor discussed by mainstream media – is why a missed approach wasn’t conducted.    

Wrote:. Continuing an unstabilised approach is a causal factor in over 40% of all approach and landing accidents.
   . Approximately 70 % of rushed and unstable approaches involve an incorrect management of the descent-and-approach profile and/or energy level (i.e., being slow and/or low, being fast and/or high).
   . 56% of commercial jet airplane accidents occur during the approach and landing phases of flight and account for 44 percent of all fatalities worldwide. The approach and landing typically accounts for 16% of the total flight time.

The stable approach criteria for Virgin Australia’s long haul operation is 1000 feet… but here they were, nearly 600 feet low on an approach (below 1000 feet), and an unstable call wasn’t called for by any crew member.

The failure to execute a missed approach should likely be a significant focus of the ATSB investigation.

...has effectively been filtered out at a commissioner level. And that IMO is absolutely criminal and tantamount to a breach of S24 of the TSI Act.

MTF? Definitely...P2  

Ps For those interested here are my running notes & some very interesting links off the convoluted ATSB website  - http://auntypru.com/wp-content/uploads/2...NOTES.docx 

[thorn bird]

Any truth in the rumour the ATSB sent a team of deep water divers to that ditching in Proserpine to recover the CVR and FDR??

[Kharon]

Duck shoving - unacceptable.

Before we begin this journey, there is some essential background information which we hope will assist the reader to follow the trail of breadcrumbs to what we believe is an inescapable conclusion.

Duck-shove is first recorded in The Australian National Dictionary from 1870 to describe the pushy behaviour of Melbourne cab drivers. It seems to have grown out of observations of ducklings, waddling in an orderly queue behind mother duck. The idea is that there’s always one little duck that is pushy, and elbows the others aside to get what it wants. If that is correct, then it means that the original duck-shoving was actually done by ducks – from where it extended to human behaviour that involves “elbowing others”. (Thanks to ABC News Radio for this excerpt)

Dictionary – avoid or evade (a responsibility or issue).
"this sniping and duck-shoving between county councils and the Electricity Commission should cease".

"..AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.."

The AIPA are, without doubt, one of the most respected associations in the aviation world with a fine track record for presenting balanced, realistic comment and solutions to ‘problem’ areas across a wide range of topics associated with ‘matters aeronautical’.  In short, no lightweight raggedy ass bunch of cowboys, but a very serious professional body, not given to making facetious claims or crying wolf.  When the AIPA make a comment, such as the quote above, you can bet it is a rock solid assessment, based on fact, not made lightly and only published after careful, due consideration.  P2 has, in the post above provided more on the topic.  The AIPA submissions to the Senate inquiries and the Forsyth Review are essential reading.   

But, we need to work backward from the P2 post, if we are to reach journeys end.  The incident under discussion is the Virgin 777 incident on a SHEED arrival to Melbourne’s Tullamarine, not the preceding one, which has quietly disappeared from public radar.  P2 goes on to highlight several divergences noted in the final report from the ATSB, particularly the differences between the IIC investigation (interim), DIP review and the final, glossy product provided after the Commissioner’s ‘review’.  Marty Khoury published a first class analysis based, in advance of the Interim report which brought several important elements into causal chain considerations; many of these were considered by the investigators in the Interim report as being pertinent.  

This brings us to our starting point.  Long before the ATSB final report was being ‘reviewed’ by the Commissioner, there would be at least three definitive, expert reports not only presented, but acted on, promptly and correctly by VA, with minimal, if any ATSB assistance.  In theory, the VA safety management system should have captured the event and provided the basis for an internal assessment at management level.  From this a plan for risk mitigation would have been developed and provided to those who would institute and manage the proposed changes. The ‘flight operations’, fleet management and Check/Training would have played their part.  In a very short time, internally at least the risks should have been mitigated, expertly, efficiently and properly.  Any Safety Recommendations to flight crew published, promulgated and delivered, in a timely manner.  

There is very little wrong, theoretically, within the airline system of safety management and risk mitigation; it is, after all what it’s supposed to do.  Whether the VA system had worked ‘properly’; or not, should be a definitive part of the ATSB investigation which examined, in detail, that area to decide whether any undue management pressure was brought to bear, even subtly on flight crew or the procedures.  One must hope that the ATSB examined this important element honestly. For it is clearly apparent that any flaw found in the first (and only) real time line of defence ignored by the ATSB could and probably would have disastrous repercussions in a repeat event.  Natural diffidence and a reluctance to hang their dirty linen outside aside; management do have a legally binding responsibility and duty of care, to ensure that things are ‘done properly’ and honestly reported.  The ATSB are equally obliged to ensure that ‘all is well ’ and provide proof positive of this; even if just a passing acknowledgement. 

In a perfect world, ATSB involvement from day one was, technically and operationally, of little use in, the first instance.  What ATSB could do was to assess the patch made by VA and accept the proposed fix or, propose (insist) on a different approach to the identified problems; assuming those matters had been correctly isolated.  With the initial patch in place, what needed to follow was a holistic appraisal of why the event occurred.  The airline knew how and moved quickly to prevent a reoccurrence but the time required for a full, in depth analysis of all factors was not within the airline’s purview.  That is a job for the ATSB, to confirm the initial findings, assess the remedy, evaluate the results and inform which ever power that be of those findings.  In this case ASA, CASA and VA.  Not do this in a proper manner defeats the purpose of ATSB risk mitigation evaluation, lets down the travelling public and betrays the faith flight crew must have in the probity of the ATSB.

This is where P2 has been digging; the results are concerning.  For starters, there is the vexed question of ‘unstable approach’.  I happen to disagree with the notion – technically, IMO the approach flown was ‘stable’ but stable on the wrong glide path.  Academic I know, but essentially this was a potential CFIT; steady as a rock right into the ground, well short of the runway, had not the error been picked up.  The question of initiating an overshoot or not could and probably will be debated; but for my two bob’s worth; visual, stable, runway in sight, I could well have been tempted to level off, maybe pitch up a little and land.  But I digress.

This discussion is not about what has been done by the airline or flight crew, but of the ATSB abysmal management of the final incident report.  To understand this, we must examine the history of several recent, very close calls at Melbourne; which holds the all time, world record high for such events; certainly over the past two years.  There is a rapidly emerging pattern.  During the two years the ATSB fiddled about with one report, there have been a number of similar events, including the event preceding ‘SHEED.   How many – good question.  P2 (research guru extraordinaire) groaned when I asked the question. The ATSB web site is a nightmare; if you want to do some serious digging.

Now here it get’s a little tricky, so bear with me; I’ll try to explain why.  Say you were to be taxed on the number of Hens, but not Ducks on your farm.  A smart operator would hide some the chickens in the duck pen, send some to his mate over the way and generally disperse the flock, to minimise the taxable total.  It gives the investigator a tough time, tracking them all down, identifying ‘yours’ and arriving at a realistic figure.  So it is for P2.  The working notes provided give you a fair idea. 

Events with similar characteristics spread out over a number of different categories, which, effectively hides the Chooks with the Ducks, in different pigeon holes.

Similar elements, similar incidents at Melbourne, similar circumstances: a short (not complete) list of potential suspects:-

Complex airspace.

Complex STAR, badly presented, easily confused tracking details (nightmare plates).

Multiple, closely spaced waypoints.  Short notice, close in changes to tracking over the same multiple, closely spaced waypoints.  

Automatics dependency (sub topics SOP and Manufacturer recommendations, which lead to company training and checking practices, back to basic flight training, experience levels and selection process, and much more).

CRM and PM practices (trend noted) related back to who's flying and who’s watching; who’s programming the computer; who checks; etc.  VA was a classic, both crew trying to sort out ‘the box’ during an 8 mile visual approach, so the AP could fly it.  

Loss of situational awareness (multiple recent events), fatigue used again as an excuse. Etc.

The list goes on, and on; but, a definitive count, topic specific and related cannot be easily found.  One must look at many categories; ‘short reports’, un finished reports, fatigue, failed to follow SOP. Etc.  Multiple, non connected pigeon holes.  A virtual extravaganza of ‘category’, all hiding their part of the true picture.  The ATSB monster jig-saw puzzle.  

I’ve run out of time: but we will; soon, begin to unravel the ATSB obfuscation jig-saw puzzle, find all the chickens and bring ‘em home.  It looks as though there is a serious pattern, a trend if you like.   I can see a dozen incidents, at Melbourne alone all of which have similarities, all of which could have been serious.  None of this has been addressed by the ATSB; and, had it not been for prompt action by airlines concerned, a repeat was always on the cards.    Maybe we are chasing our tails; or, maybe there should be some heavy duty SR out there, heading to CASA and ASA.  Can’t say for certain just yet; but, stay tuned.

Toot toot.

[Gobbledock]

Astute 'K';

"The ATSB web site is a nightmare; if you want to do some serious digging"

There is a very good reason why it is like that, and it's not by accident......naughty sly, sneaky Beaker.

Eloquent 'K';

"It looks as though there is a serious pattern, a trend if you like. I can see a dozen incidents, at Melbourne alone all of which have similarities, all of which could have been serious.  None of this has been addressed by the ATSB; and, had it not been for prompt action by airlines concerned, a repeat was always on the cards"

This is of real concern, yet it is hardly surprising considering what an embarrassment Herr Beaker is. What will it take to get the rudderless ATsB to investigate an emerging trend like this properly - a smoking hole bang on the Tulla piano keys??

Tick tock......