[Peetwo]

Popinjay continues to take the PISS on ICAO Annex 13 compliance??

Via ICAO:

Per Annex 13, the State conducting the investigation of an accident or incident is expected to produce a Preliminary Report within 30 days of the accident. This Preliminary Report may be public or confidential at the discretion of the State in charge.

Courtesy Popinjay HQ, prelim report AO-2023-051 was released 89 days after the fatal accident occurred...

Via, PJ's bureaucratic top-cover, load of absolute self-serving (un-interactive) media release bollocks...

Preliminary report details initial evidence gathered in Hawks Nest R66 helicopter accident


The accident helicopter’s flight path

The Australian Transport Safety Bureau has released a preliminary report from its ongoing investigation into a Robinson R66 helicopter’s in-flight break-up and collision with water near Hawks Nest, NSW on 26 October 2023.

“Today’s preliminary report provides factual information from the initial evidence gathering phase of the investigation, including detailing this tragic accident’s sequence of events,” ATSB Chief Commissioner Angus Mitchell said.

About half an hour before the accident, the helicopter departed Cessnock for Wallis Island, on the NSW north coast, and initially tracked east towards Newcastle, flying close to the cloud base, which was between 500 ft and 1,000 ft above ground level.

Approaching the coast, the pilot received clearance from Williamtown air traffic control to transit Williamtown airspace northbound at 500 ft above mean sea level (AMSL).

As the helicopter reached Anna Bay, Williamtown air traffic control then provided the pilot with a further clearance to follow the coastal VFR route below 2,000 ft AMSL.

“The helicopter’s onboard video camera showed at this time that the helicopter’s autopilot was engaged, with heading hold and altitude mode selected,” ATSB Chief Commissioner Angus Mitchell said.

As it tracked towards Hawks Nest, the helicopter passed over the south shoreline of Yacaaba Headland, to the west of Mount Yacaaba, at about 900 ft AMSL.

Analysis of the onboard video footage showed that the helicopter then experienced a series of initially minor changes in roll, pitch and yaw, and the pilot began to make cyclic inputs, overriding the autopilot.

“As the helicopter passed north of Yacaaba Headland and over Providence Bay it rolled left slightly, then right and left to bank angles of about 10 to 15 degrees. During this time, the nose remained pitched up at about 6 degrees and the helicopter climbed to about 1,100 ft AMSL,” Mr Mitchell said.

“Subsequently the helicopter’s nose pitched down and it rolled to the right, becoming completely inverted, and continuing to roll right to about 270 degrees.”

The ATSB’s subsequent wreckage examination determined that, during the accident sequence, the main rotor likely impacted the cabin and struck and separated the tail boom aft of the engine fairing.

The helicopter impacted the waters of Providence Bay, near Hawks Nest, and the pilot was fatally injured.

Mr Mitchell noted that the helicopter’s onboard camera is proving invaluable to the investigation, as it not only recorded the in-cabin visual and audio environment, but also captured GPS position, acceleration, and rotational speed.

“We were very fortunate that a roof panel to which the camera was mounted washed up on the beach near the accident site and was located by a member of the public who provided it to the NSW Police,” Mr Mitchell said.

“The video files and other recorded data were subsequently extracted from the camera memory module at the ATSB’s technical facilities in Canberra.”

Williamtown air traffic control radar and radio communications between the helicopter have also been retained by the ATSB for analysis.

“As we continue the investigation we will further analyse the onboard video, continue to examine recovered components, and look into flight planning and helicopter performance, amongst other aspects,” Mr Mitchell said.

“Investigators are also closely examining the meteorological conditions at the time of the accident, particularly in the immediate vicinity of Mount Yacaaba.”

The ATSB’s final investigation report will detail findings, any identified safety issues, and safety actions taken to address those.

“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.”

Read the preliminary report: Loss of control and in-flight break-up involving Robinson R66, VH-KFT, near Hawks Nest, New South Wales, on 26 October 2023

Publication Date: 23/01/2024

 
“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.” - Hmm...the funny thing is although this bollocks statement is continuously regurgitated in all ATSB preliminary reports and associated bollocks MRs, there is in fact no longer any 'critical safety issue' definition published on the ATSB website - see previous post...

However a CSI is annually defined (for at least the last 5 years) in the ATSB Annual Report - WTD??

Via ATSB Transparency Portal:

Formal safety issues and actions

ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:

• can reasonably be regarded as having the potential to adversely affect the safety of future operations
  
• are characteristics of an organisation or a system, rather than of a specific individual, or operational environment at a specific point in time.
  

Safety issues will usually refer to an organisation's risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.

The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the TSI Act to make a formal safety recommendation either during or at the end of an investigation – depending on the level of risk associated with a safety issue and the extent of corrective action already taken.

When safety recommendations are issued, they clearly describe the safety issue of concern, but they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue, and act appropriately.

When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.

The ATSB can also issue a safety advisory notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.

Safety issues are broadly classified in terms of their level of risk:

• Critical safety issue – associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.
  
• Other safety issue – associated with a risk level regarded as unacceptable unless it is kept as low as reasonably practicable. Where there is a reasonable expectation that safety action could be taken in response to reduce risk, the ATSB will issue a safety recommendation to the appropriate agency when proactive safety action is not forthcoming.
  

All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.

       
MTF...P2 

[Peetwo]

Popinjay continues to take the PISS on ICAO Annex 13 compliance - Part II

From the 2019 ANAO audit of the ATSB: "Efficiency of the Investigation of Transport Accidents and Safety Occurrences"

Read from CH 2 "Measuring and supporting operational efficiency":

Areas examined

The ANAO examined whether the ATSB had established efficient processes for the investigation of transport accidents and safety occurrences.

Conclusion

The ATSB has established key elements of an overall framework to promote efficient investigation processes. There is a focus on clearing the backlog of investigations that have been underway for some time, applying sound processes to decide which notifications merit a safety investigation, and adjusting key performance indicators to identify more realistic completion timeframes for the more complex investigations. The ATSB has also taken a number of actions to give greater attention to the efficiency with which it undertakes transport safety investigations.

Areas for improvement

The ANAO has made two recommendations. One relates to short investigations, where recent changed processes have had an adverse impact on completion timeframes.

The second encourages the ATSB to marry its increased focus on timeframe efficiency with greater attention to the resource efficiency of its investigations.

You will even find there is a reference to ICAO -  :

2.10 In October 2018, the ATSB advised the ANAO that the target of completing 90 per cent of complex investigations within 12 months was driven by the ATSB’s perspective as to what may be considered acceptable to industry and directly involved parties, including the next of kin. The ATSB further advised the ANAO that the 12 month target also took into account the International Civil Aviation Organization’s (ICAO) International Standards and Recommended Practices manual ‘Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Eleventh Edition, July 2016’ (Annex 13). Specifically, section 6.5 of Annex 13 states:

In the interest of accident prevention, the State conducting the investigation of an accident or incident shall make the Final Report publicly available as soon as possible, and if possible, within twelve months.

However for this post I am more interested the following recommendation for the completion of 'short' investigation:

Recommendation no.1

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

Australian Transport Safety Bureau response: Agreed.

2.9 The ATSB acknowledges the average increase in time taken to complete short investigations since 2016–17. The ATSB plans to address this issue through the allocation of dedicated investigator resources, within the current organisational structure, to short investigations.

Then refer to page 25 'Results against key performance criteria' table of Popinjay's 2022-23 Annual Report

Median time to complete investigations.

Target - Short 7 months/ Defined 14 months/ Systemic 20 months
Result - Short 10.4 months/ Defined 15.9 months/ Systemic 38.5 months

With all of the above in mind and in stiff competition, has Popinjay taken the record for the longest completion of a short investigation?

Last Wednesday the latest bollocks Media Release with Godlike attributed as the DTS was put out:

Diversion due to fuel imbalance and engine shutdown emphasises importance of checklist diligence



A Boeing 737’s crossfeed valve was not closed after a pre-flight fuel transfer, later resulting in a fuel imbalance warning which led to the flight crew unnecessarily shutting down one of the aircraft’s engines, an ATSB investigation report details.

Just after reaching cruise altitude on a Perth to Adelaide flight on 25 October 2021, the captain and first officer of a Qantas 737 were alerted to a fuel imbalance, indicating there were unequal quantities of fuel in the left and right main fuel tanks, located in each wing of the aircraft.

Prior to the flight, the captain had identified extensive cold soaked fuel frost on the wings, due to cold fuel remaining in the main tanks from the aircraft’s previous flight.

“To remedy this, the cold fuel was transferred to the centre tank, and the main tanks were refuelled with additional, warmer fuel,” ATSB Director Transport Safety Dr Stuart Godley said.

“The procedures required the crossfeed valve to be closed when the operation was completed, however, the valve was not closed. This was likely associated with the crew following the maintenance engineer’s verbal instructions rather than referring to the relevant procedure. While this is permissible, referring to procedures is a more reliable method to ensure all steps are carried out.”

During pre-flight checks, and later during the climb and level-off, the pilots did not notice the crossfeed selector in the open position, or the associated dimmed blue indicator light on the fuel panel.

Once the centre fuel tank was exhausted and its pumps were switched off, the open crossfeed valve allowed fuel to be continually pumped from the left main tank to the right engine, as a result of uneven fuel pump pressures.

While the aircraft’s manuals stated this could occur, the flight crew did not recall this, and the Boeing 737 imbalance checklist, worked through by the flight crew, did not provide sufficient guidance for an open crossfeed valve to be identified as the potential reason for a fuel imbalance.

“This led the flight crew to decide there could be a fuel leak and then, partly as a result of confirmation bias, stress and perceived time pressure as the aircraft approached the Great Australian Bight where it would fly over water, they abbreviated the relevant checklists and mistakenly confirmed a fuel leak as the cause for the imbalance.”

The ATSB’s report notes the flight crew, when working through the fuel engine leak checklist, inadvertently performed a step out of sequence, invalidating the process, and contributing to their conclusion that there was a fuel leak.

As a result of this incorrect confirmation, the flight crew unnecessarily shut down the aircraft’s left engine during flight.

After the flight crew diverted to Kalgoorlie and conducted a single-engine landing, a post-flight inspection revealed there was no fuel leak, and the fuel system was serviceable.

Dr Godley noted that, although the presence of information in the checklist about the effect of an open crossfeed valve probably would have led to a different outcome in this case, a fuel imbalance condition is itself usually a minor condition, and the ATSB considered the checklists adequate to address a more serious condition such as a fuel leak.

“This incident highlights the importance to all pilots of being precise when following checklists, especially when under stress,” Dr Godley said.

“Checklists are designed to minimise performance variability under workload and stress, increasing the likelihood that all required actions are successfully carried out.”

Read the report: Fuel imbalance and engine shutdown involving Boeing 737, VH-VZT 135 NM south of Kalgoorlie-Boulder Aerodrome, Western Australia, on 25 October 2021

Publication Date 28/02/2024

Note that in the report there was no safety issues identified and in the 'safety action' section it simply has:

Safety action by Qantas Airways
After the occurrence, Qantas communicated the factors involved to 737 flight crews.

Presumably the internal investigation and subsequent initiated safety action of Qantas were completed within a relatively short time frame? However this short investigation took 857 days, or more than 4x the target performance (KPI) time to complete?? - UDB!

MTF...P2

PS: Wonder why the following contextual information was not mentioned in the Godlike blurb or in the 'contributory factors' section of the report:

Personnel information

Captain

The captain held an Air Transport Pilot (Aeroplane) Licence (ATPL) and was appropriately qualified and authorised to conduct the flight. The captain had almost 12,000 hours total flying experience with over 5,000 hours on 737 variants. The captain was a check and training pilot for the operator and had flown about 110 hours in the previous 90 days.

As a result of the Qantas response measures to COVID-19[12], the captain was stood down from mid-April 2020 until 23 September 2020. Upon completion of simulator training, they returned to flying duties at the end of September 2020. Although the captain remained stood up after that time, their monthly rostered flying hours were lower than was usual prior to the pandemic. In the 12 months prior to the event, they flew 40% of the hours they had flown in the 12 months prior to stand down. In the 3 months immediately prior to the event flight, their monthly average flying hours were roughly half their pre-pandemic average. The captain reported that while being comfortable to fly, because of the stand down and reduced flying hours, they noted a degradation in their skills.

First officer

The FO held a Commercial Pilot (Aeroplane) Licence and was appropriately qualified and authorised to conduct the flight. The FO had about 1800 hours total flying experience and about 110 hours on the 737. The FO had flown about 24 hours in the previous 90 days. The FO was undergoing line training and was qualified to act as a first officer on revenue flights alongside a check and training captain.

The FO joined Qantas as a second officer on the Boeing 787 fleet. In 2019 they commenced FO promotion and 737 type rating training, however soon after this was delayed. The FO’s training recommenced in May 2021. As a result of Qantas’ COVID-19 response measures, the FO was stood down between September and October 2021, re-commencing flying duties mid-October 2021.

[Peetwo]

State of Aviation Safety Downunda - 

Via Oz Flying:

CASA issues On-Condition Reminder
24 July 2024


CASA this week released an Airworthiness Bulletin reminding engineers about the monitoring requirements for on-condition maintenance.

AWB 02-001 dated 23 July was issued in response to an ATSB investigation into a fire and fatal crash involving a Mooney M20 near Luskintyre, NSW, in 2022.

The AWB states that some engineers appear to have forgotten that "on condition" requires active monitoring such as repetitive inspections or tests to ensure the component or system remains functional.

"Some operators and maintainers, including some Licensed Aircraft Maintenance Engineers (LAMEs) have come to believe that 'on condition' means fit and forget," the AWB points out. "They believe that it’s OK to not do anything until a failure occurs.

"Maintenance practices that mistakenly equate 'on condition' to mean 'fit-and-forget' and/or 'fit-until-failure' will not achieve the levels of safety and reliability that are inherent in the design of the aircraft.

"At best, this may cause operational surprises, which could prove very costly. At worst, this may jeopardise the safety of an aircraft and its occupants."

On-condition maintenance refers to the inspections and checks used to detect degradation in condition or performance. Items are left in service on the condition that they continue to meet a desired physical condition and performance standard.

Most commonly, engines of aircraft in the private and air work categories can be run on condition, which enables the aircraft owner to bypass the TBO time provided an engineer is satisfied with the engine. An engine needs to be re-inspected and signed-off again at the next periodical check.

"The item's performance may relate to, but are not limited to, cleanliness, cracks, deformation, corrosion, wear, pressure or temperature limits, leaks, loose or missing fasteners, and are published in the approved data of the aircraft or aircraft component," the AWB states.

"Therefore on condition maintenance means an inspection / check that may result in the removal of an item before it fails in service."

Mooney VH-UDQ crashed in 2022 after an O-ring on the engine-driven fuel pump failed due to deterioration, causing a fire in the engine compartment. Although the pilot attempted an emergency landing, the aircraft struck trees short of the airport. The pilot later died in hospital.

Here is a link for the AWB published on the 23 July: https://www.casa.gov.au/sites/default/fi...enance.pdf

Couple of OBS on this AWB associated with an ATSB SAN issued in conjunction with the final report of 'Short investigation' AO-2022-049.

To begin this was the bollocks fictional Popinjay media release associated with release of the final report:

ATSB urges proactive approach to replacing elastomer components after O-ring failure contributed to Luskintyre in-flight fire accident

Piston aircraft operators and maintainers are urged to proactively replace O-ring seals within fluid-carrying components of their aircraft before they naturally deteriorate from age, after a Mooney fatal in-flight fire near Luskintyre, NSW on 17 October 2022.

The ATSB has issued the safety advisory with the release of its investigation report from the accident where a pilot was fatally injured when the Mooney M20J they were flying caught fire in flight, and collided with terrain short of the runway at Luskintyre Airfield.

The Mooney had taken off from Maitland for a local flight, and flew to and around Cessnock, before heading north-east to Luskintyre.

“The Mooney had just completed a left orbit of the airfield when witnesses observed the aircraft descending to land, and reported seeing smoke and flames trailing the aircraft,” ATSB Chief Commissioner Angus Mitchell said.

The aircraft collided with terrain near the threshold of Luskintyre’s runway 30. While the pilot survived the collision, they later succumbed to injuries associated with an intense post-impact fire.

“The ATSB investigation determined fuel leaking from an age-affected O-ring seal of the engine-driven fuel pump ignited and caused an engine compartment fire,” Mr Mitchell said.

“A leak from the pump outlet fitting that supplied the engine fuel control unit was identified, and analysis indicated the O-ring sealing that fitting had deteriorated with age.”

Piston engines, and the components necessary for their operation, installed in aircraft operating in the private or airwork category are permitted to remain in service beyond their recommended calendar time overhaul interval, the investigation report notes.

Aircraft records indicated the pump had been in service for more than 29 years and had likely remained undisturbed for maintenance throughout that period.

“Inspect the uninspected,” Mr Mitchell said.

“If aircraft records identify elastomer – rubber-based – type components that have remained undisturbed for significant periods of time, take a proactive approach – replace components such as O-ring seals before they deteriorate to the point of failure.”

The ATSB’s final report also notes the finding that the aircraft had been recently refurbished.

“This refurbishment included repainting the aircraft, and replacing interior furnishings with alternate materials, but neither the refurbishment, nor the flammability assessment of the substituted materials, were recorded in the aircraft’s log books,” Mr Mitchell explained.

“While the effect this had on the in-flight fire or survivability in this case could not be determined, aircraft owners should be sure to document refurbishment action in the log book, and include details of materials if substituted, as well as their suitability for use in aircraft interiors.”

Read the report:  In-flight fire and collision with terrain involving Mooney Aircraft Corporation M20J, VH-UDQ, near Luskintyre Airfield, NSW on 17 October 2022

Read the Safety Advisory Notice: On condition? Replacing O-ring seals before age catches up.

Publication Date
07/05/2024

Notes: 

• The 'Short' investigation had no associated preliminary or interim reports and took 18 months and 21 days to complete. One wonders when the investigators discovered the leaking age effected fuel O-ring seal?? 
  
• The issue date for this important SAN was on the same day the final report was released IE 07/05/24
  

Safety Action by the Civil Aviation Safety Authority

In response to the investigation finding related to deteriorated O-ring seals, the Civil Aviation Safety Authority proposed to review Airworthiness Bulletins AWB 02-001 and AWB 85-004 and most likely update them. The update would serve as a reminder to industry of some of the concepts and philosophy related to ‘on-condition’, which is not a ‘fit and forget’ approach to preventative maintenance.  

• It took CASA at least 78 days to 'review' and 'update' the AWB on a safety issue that was most likely identified within weeks of the accident occurring.
  

Our state aviation safety system in action - we're definitely the envy of the world...

MTF...P2 

[Peetwo]

Popinjay to the rescue with AO-2024-035 Prelim report..etc - 

On 4 September PJ was attributed to this bollocks media spin, announcing the Annex 13 non-conforming (by 53 days) prelim report release for Short investigation AO-2024-035...
   

Preliminary report details passenger 737 flight below minimum safe altitude near Canberra


A preliminary report from the ATSB’s on-going investigation into a flight below minimum altitude incident involving a Boeing 737 south of Canberra notes the operator involved has taken a number of proactive safety actions. 

On the evening of 13 June 2024, the Boeing 737-800 had departed Denpasar, Indonesia, operating Batik Air’s inaugural flight to Canberra, the report details. Forecast tailwinds resulted in an estimated arrival time just prior to 0600 on 14 June, which was earlier than planned, and before Canberra Tower and Canberra Approach air traffic control commenced services for the day. 

The crew elected to proceed, without delaying to wait for those air traffic services to become available, which meant arriving in Canberra using the Canberra Airport CTAF (common traffic advisory frequency – where pilots use radio calls to announce their positions and arrange separation from other aircraft). 

As the aircraft descended in darkness towards Canberra, the crew prepared to conduct the AVBEG 5A standard arrival route (or STAR – which uses satellite-based positioning waypoints to transition aircraft from en route flight to, in this case, an initial approach fix waypoint for Canberra Airport’s instrument landing system approach). 

“While the crew intended to fly the STAR, they did not request this from the air traffic controller managing the airspace,” ATSB Chief Commissioner Angus Mitchell said. 

Instead, the controller expected the crew to track along the clearance previously provided direct to Canberra Airport from the AVBEG waypoint, which is to the north-west of the airport and is also the first waypoint of the AVBEG 5A STAR. 

The crew proceeded with their planned standard arrival route, which meant the aircraft deviated from the cleared track direct to Canberra, and instead tracked to a series of waypoints to the south-west and south of the airport. 
The controller, unaware of the flight crew’s intentions, did not query the deviation, but did instruct them to maintain 10,000 ft to remain clear of a restricted area around the Deep Space Communications Complex at Tidbinbilla to the west of Canberra (this separation is built into the STAR).  

“After receiving this instruction, the flight crew became uncertain as to whether the aircraft would be operating within, or outside of, controlled airspace during the standard arrival route and approach,” Mr Mitchell explained. 
After levelling the aircraft at 10,000 ft, the crew subsequently requested ATC clearance to conduct the instrument landing system (ILS) approach to Canberra. The controller advised them that the Canberra tower was closed and that CTAF procedures applied for the airspace.  

A short time later, when tracking towards the airport from the south and having descended outside of controlled airspace, the flight crew identified they were above the desired flightpath, and the captain decided to conduct a holding pattern at the approach waypoint of MOMBI to reduce altitude. 

“During this holding pattern, the aircraft levelled out at 4,700 ft, but this meant it descended below minimum holding altitude of 5,600 ft, and at one point the aircraft passed 924 ft above terrain,” Mr Mitchell said. 

After rejoining the approach, the aircraft commenced descending again, following the runway 35 glidepath, and it landed without further incident. 

The report notes that while the aircraft was in the holding pattern, a controller in the Canberra Tower was preparing to commence the tower service for the day and they observed the aircraft below the minimum holding attitude. 

“The Tower controller made multiple attempts to contact the crew on the Canberra CTAF, but did not receive a response,” Mr Mitchell explained. 

At about the same time, the Canberra Approach controller commenced for the day – taking over the frequency the flight crew were listening to – and issued a safety alert that the aircraft was operating below the minimum safe altitude. 

The flight crew responded that they were visual with the runway and continued their approach. 

The ATSB’s continuing investigation will consider, among other elements, Batik Air’s procedures, training and route implementation processes, as well as air traffic control procedures and training. 

“A final report with analysis and findings will be released at the conclusion of the investigation, but we note the operator has already pro-actively taken safety actions,” Mr Mitchell concluded. 

“These include revising their Canberra Airport briefing documentation, issuing flight crew notices highlighting procedures for operating in non-controlled airspace, and rescheduling flights to Canberra to ensure they arrive during air traffic control operating hours.” 

Read the preliminary report: Flight below minimum altitude involving Boeing 737, PK-LDK, 19 km south of Canberra Airport, Australian Capital Territory, on 14 June 2024

Publication Date: 04/09/2024

Hmm...I guess Batik Air is fair and uncontroversial game, being as it's an international operator not associated with QF or VA. However what is the point of continuing with this investigation and having PJ contributing 'attributable to' commentary, that effectively says the operator has already addressed the safety issues identified? 

Next we get DTS Dr Godlike being attributed to this media report announcing the release of SAN AO-2024-013-SAN-01

Chipmunk owners urged to ensure rivets are maintained to specifications following Jandakot accident



The ATSB advises DHC-1 Chipmunk maintainers and owners that crashworthiness could be significantly compromised if incorrect specification rivets are used.

The safety advisory notice has been issued as part of the ATSB’s continuing investigation into a fatal accident involving a Chipmunk at Jandakot Airport, WA, on 26 April 2024. 

As detailed in a preliminary report in July, shortly after take-off the aircraft was observed turning to the left at a low height before colliding with the ground, fatally injuring the pilot.

During the ongoing investigation the ATSB has identified that non-specification rivets had been installed on the aircraft, attaching the upper structure between the front and rear cockpits to the fuselage. This structure provides the attach point for the front cockpit shoulder harness.

“Two sets of rivets – 12 in total – attaching the structure to the fuselage sheared during the accident,” Director Transport Safety Dr Stuart Godley said. 

“The ATSB found that the rear row of rivets in each set – that is, three of the six rivets on each side – were pure or near-pure aluminium.”

This meant the rivets did not meet the specification of the relevant modification.

“Testing indicated a significant reduction in strength, estimated to be about one-third of the specification strength,” Dr Godley said.

The rivets would have been originally replaced during the embodiment of modification H.268, issued in 1966 by the aircraft’s type certificate holder at the time, Hawker Siddeley, to replace alloy structure elements with steel.
The aircraft may have modified in the 1960s, however the ATSB has not determined precisely when, or if, the rivets had been replaced since the modification.

It is important to note that while the crashworthiness of the aircraft had been compromised by the presence of non-specification rivets, the ATSB has yet to establish whether it contributed to the outcome of this accident.

However, as there is the potential for other Chipmunks to have incorrect rivets installed in this location, the ATSB determined it was important to bring the issue to the wider attention of Chipmunk operators.

“The ATSB’s safety advisory notice highlights the importance of maintaining aircraft crashworthiness design elements, including its restraint system, to keep the occupant within an aircraft’s ‘living space’ during an accident sequence,” Dr Godley said.

“The use of upper torso restraints such as a shoulder harness can prevent the occupant from striking the surrounding structure during an accident. It is crucial that all components forming part of that restraint system and the structures to which they are attached are maintained to defined specifications.”

The notice therefore advises DHC-1 Chipmunk maintainers and owners to be aware that fitment of incorrect specification rivets where the upper structure between the front and rear cockpits attaches to the gussets on either side could significantly compromise the crashworthiness of the aircraft.

“Those conducting work on aircraft must ensure modifications are carried out to the required specification, or during maintenance returned to that specification,” Dr Godley concluded.

The investigation is continuing, and the ATSB will issue a final report, which will detail findings and analysis, at the conclusion of the investigation.

Read the Safety Advisory Notice: DHC-1 Chipmunks may have incorrect rivets fitted

Publication Date:
11/09/2024

I guess kudos for the proactive initiative of releasing a SAN, however I'm not sure why Dr Godlike needs to be involved? I also query the timetable on when the safety issue was 1st identified to the release of the SAN nearly 5 months after the accident occurred?

Next 'attributed to' DTS Stewie Macleod announcing the release and findings of Short investigation AO-2022-066 (note the excuse for the delay in the investigation):

Saab 340 engine failure due to incorrectly seated coupling securing hydro-mechanical unit to accessory gearbox


The right engine of a Saab 340 flamed out shortly after the aircraft reached cruising altitude, after the engine’s hydro-mechanical unit driveshaft decoupled from the accessory gearbox due to an incorrectly seated coupling, leading to a fuel pump failure, an ATSB investigation report details.

The aircraft, with 2 flight crew, 1 cabin crew and 32 passengers on board, was operating a scheduled Regional Express service from Perth to Albany, WA, on the evening of 21 December 2022.

After climbing to 15,000 ft and establishing a direct track to Albany, the flight crew felt 2 bumps pass through the airframe, and felt the aircraft yaw.

Identifying that the right engine had failed, they conducted the associated checklists, secured the right engine, and returned to Perth where the aircraft landed without further incident.

“The ATSB’s investigation found that the right engine’s hydro-mechanical unit was incorrectly seated, resulting in a misalignment with the engine’s accessory gearbox, leading to significant wear and the eventual decoupling of the hydro‑mechanical unit’s drive shaft from the accessory gearbox,” ATSB Director Transport Safety Stuart Macleod explained.

“As a result, the fuel pump within the hydro-mechanical unit could not function, leading to the engine flameout.”
The engine, a GE Aerospace CT7, was removed from the aircraft for inspection at an authorised CT7 maintenance facility.

“While this inspection put the ATSB investigation on hold for an extended period, it did reveal that the V-band coupling securing the flanges of the hydro-mechanical unit to the accessory gearbox had wear on its inner surface from contact with the accessory gearbox flange,” Mr Macleod noted.

“Interference wear in this area was evidence of a misalignment and non-seating of the hydro‑mechanical unit onto the accessory gearbox.”

Maintenance records showed that the last recorded maintenance that required installation of the hydro-mechanical unit onto the accessory gearbox was during an engine workshop visit at a contractor maintenance facility in February 2018.

“This incident highlights that the incorrect alignment or seating of an aircraft or engine component may not be readily apparent after the installation of a V-band coupling or clamp,” Mr Macleod said. 

“As such it serves as a reminder to maintenance personnel installing V-band couplings to ensure the correct seating and alignment of flanges and the V-band coupling prior to the fitment and torquing of attaching hardware.”

Regional Express has since commenced a fleetwide inspection of its Saab aircraft to confirm the correct fitment of the V-band coupling, while GE Aerospace intends to share the learnings of this occurrence with its customers and maintenance facilities.

Read the report: Engine failure involving Saab 340B, VH-RXE, 141 km south of Perth, Western Australia, on 21 December 2022

Publication Date:
12/09/2024

MTF...P2

[Peetwo]

Popinjay releases AO-2024-003 Short, AO-2024-037 Prelim - 

Via PJ media minions, 1st from attributable to DTS Stewie Macleod a short investigation that actually falls six days within the performance indicator for a short investigation. However was it actually necessary for the PJ crew to continue with this investigation and to highlight with yet another bollocks 'attributable to' DTS MR -  :

King Air control issues demonstrate importance of aircraft system knowledge, handbook familiarity



An incident in which a King Air pilot encountered instrument failure and control issues over Western Australia is a reminder of the value of aircraft system knowledge and pilot operating handbook familiarity, an ATSB final report notes.

On 25 January 2024, the twin turboprop King Air C90A aircraft departed Kalgoorlie-Boulder Airport for a charter flight to Warburton, with one pilot and two passengers on board.

About half an hour into the flight, operating in instrument meteorological conditions, the pilot was cleared by air traffic control to divert left of track to avoid a storm.

With the autopilot in heading mode, the pilot used the heading bug on the horizontal situation indicator to track left. Once past the storm, the pilot changed the heading setting to the right, to re-intercept the original track.

“Unknown to the pilot, the aircraft’s remote gyroscope had failed, resulting in erroneous indications on the horizontal situation indicator,” Director Transport Safety Stuart Macleod said.

This resulted in a sustained, uncommanded right turn.

Observing the aircraft continue to turn right through the selected heading, the pilot disengaged the autopilot and hand-flew the aircraft onto the correct heading.

During the manoeuvring, altitude variations between -400 ft and +900 ft were recorded on ADS‑B tracking services.

Having observed the aircraft deviate laterally and vertically, the monitoring air traffic controller queried the pilot’s intentions several times.

“The combination of manually flying in instrument meteorological conditions, troubleshooting and interactions from ATC resulted in a high workload situation for the pilot,” Mr Macleod observed.

A short time later, contrary to the pilot operating handbook, the pilot re-engaged the autopilot in heading mode, and made continual left inputs to the heading bug to keep the aircraft tracking left. 

“This contributed to high workload and sustained control issues,” Mr Macleod said.

“Additionally, the pilot not making a PAN PAN broadcast to ATC reduced the opportunity for the controller to provide appropriate assistance.”

The pilot elected to return to Kalgoorlie, and landed without incident.

The ATSB’s final report notes the occurrence highlights the value of aircraft system knowledge and pilot operating handbook familiarity in resolving malfunctions.

“This incident emphasises the importance of pilots utilising all options to reduce their workload, including requesting assistance from air traffic services when they recognise an emergency situation developing,” Mr Macleod said.

“Controllers are also reminded that a pilot in difficulty may not immediately alert air traffic services if they are disoriented or focused on flying the aircraft. If a controller assesses they may be able to assist, this should be communicated proactively.”

Read the report: Instrument failure and control issues involving Raytheon Aircraft Company C90A, VH-JEO, 170 km north-east of Kalgoorlie-Boulder Airport, Western Australia, on 25 January 2024

Publication Date:
17/09/2024

Next, from attributable to' DTS Kerri Hughes, the AO-2024-037 Short fatal investigation Prelim report, that was published 54 days past the compliance date for ICAO Annex 13 investigations?? -

ATSB releases Mulgathing sheep spotting accident investigation preliminary report



The ATSB has released its preliminary report from its on-going investigation into a collision with terrain involving a Cessna 172 during mustering at Mulgathing Station in central South Australia.

The preliminary report details factual information established in the investigation’s early evidence collection phase. It does not contain analysis or findings, which will be detailed in the final report to be released at the conclusion of the investigation.

The single-engine Cessna was being used for sheep spotting operations, flown by a solo pilot, on 27 June 2024.
At about 0810 local time, a witness on a motorbike about 500 m away observed the aircraft dive down on what they presumed was a mob of sheep, to an altitude of about 50 ft above the ground, before climbing rapidly, turning to the left and then nosediving towards the ground.

The pilot was fatally injured and the aircraft was destroyed in the accident.

ATSB investigators deployed to the site and found the aircraft impacted in about a 70° pitch down attitude, with ground impact marks directly under the nose showing no forward momentum.

“Investigators did not identify any pre-existing faults or pre-impact defects with the aircraft’s flight controls and structure,” Director Transport Safety Kerri Hughes said.

“Additionally, one of the propeller blades showed significant rotational abrasion damage and chord-wise twisting indicating that the engine was driving the propeller under significant power at the time of impact.”

Along with an on-site examination of the wreckage, to-date ATSB investigators have interviewed witnesses and gathered electronic devices from the accident site.

As the investigation progresses, it will include consideration of witness information, and examination of a GPS device recovered from the site, the aircraft’s maintenance history, aircraft weight and balance, performance considerations, meteorological conditions, the impact sequence and survivability.

“Investigators will also consider the conduct of similar flight operations, pilot qualifications and the regulatory requirements for fixed-wing aerial mustering,” Ms Hughes said.

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

A final report will be released at the conclusion of the investigation. 

Read the preliminary report: Collision with terrain involving Cessna 172N, VH-SQO, near Mulgathing, South Australia, on 27 June 2024

Publication Date:
18/09/2024

MTF...P2

[Kharon]

Seriously?

ATSB - “At about 0810 local time, a witness on a motorbike about 500 m away observed the aircraft dive down on what they presumed was a mob of sheep, to an altitude of about 50 ft above the ground, before climbing rapidly, turning to the left and then nosediving towards the ground.”.

If you read that statement in a newspaper, or heard it prattled by a talking head on 'the box'; there's a fair chance you'd shrug, ignore and decide to wait for the ATSB report. BUT WAIT ! – this is the ATSB preliminary report. Ye gods.

Who cares if 'the witness' was aback a horse; in his pajamas or sat on a fence post; of course, the 'mob' of sheep are highly relevant to the 'investigation' ;and, the assessment of the flight path of great technical value to the investigation. 'Nose diving' being especially beneficial to the final report.

Seriously, is this the best ATSB can come up with?

“A superior pilot uses his superior judgment to avoid situations which require the use of his superior skill”.

A big part of that 'skill' is grounded in the training and checking of the pilot as scripted; low level flight demands both, ask any of the crop dusting fraternity. This cheap, glib, throwaway report IMO belittles the demands of low level operations and begs some serious questions of the training provided. There are 'lessons' (not learnings {Grrr}) to take away from this fatal – let the idiot media write the rubbish, industry expects better from the ATSB. Much better.

P.S. The C90 incident could also stand some scrutiny – same deal, same questions.

Toot toot.....