[Kharon]

The Nitty Gritty.

Which only leaves ATSB and a hapless, re bearded Beaker – one texted comment cracked me up – it suggested the beard is used as cover for telling the really big Porkies.  Foley did well on MH 370 – he seems to be across the brief and manages to give an impression of honesty.  The session is worth reviewing – Norfolk and Pel-Air were mentioned and the bearded one looked distinctly uncomfortable during that interlude.  MTF.

The inestimable Fawcett.  Watch as he demonstrates, emphatically, why the Committee needs him on the paddock – every game.  Nice to see him out for a run.  

Part III @ 0230 Beaker babbles trying to dodge the question, eventually DF lets him slither away; only to lead him straight to the Pel-Air aftermath.  Off the hook? No way NX; picks up the ball at 06.00 and drives the nail home, with Bullock running interference.  Back to DF playing at 5/8 (old money) for the coup de grace, a dire warning delivered clear as crystal.  As the clock ticks down to the final moments – watch the Beaker expressions from 10.40 and the speed it moves at when Heff blows the whistle and team Beaker limp off.  Except for Beaker who is out of the chair like his nuts was a’fire. Bravo committee.  

It’s good to see all that ‘on the record’ and the record being used as a lethal weapon.  The Chambers Report still features, it is a two edged sword and with any luck the malign intent of that document will become apparent – once the Committee decide to stop using it as a handy club and start using it as a rapier.  That’s is for the CASA thread.  

Parts I & II – the MH 370 stuff up; I wonder does the world realise that the chair of our esteemed, aviation savvy Senate Committee regards it as a “stuff up”, which is Ozspeak for a right royal duck up – or, a load of Bollocks.  The most telling statements, the full stop deadline on the search, has been decided.

Then we get to Norfolk – "initial assessment of conditions" – Beaker really does believe he can get away with curling his toes up, so they can’t put his socks on – purblind folly.   The gig is up and the clock is ticking – as the chair remarked; do not ask a question if you don’t know the answer. Bye bye Beaker – watch Merde’k, the master of the game.

Hansard is brilliant; but, the video – is bloody marvellous, thank tech crew as always a great job.

MTF – fair bet.

Toot toot.

[Gobbledock]

Of gentlemen and dipshits

Video 1: Fawcett ran circles around the bearded buffoon. For most of the questioning all the 'Beard on/Beaker' could do was mutter and wobble his head like an Indian taxi driver! I was impressed how the Senators teamed up to give weight behind the need to compensate Dom and Karen! They did this eloquently and in a carefully worded manner. It was heartening to see somebody looking out for the well being of the small people in this world.

Video 2: Oh dear, Mr Foley, this is senate estimates sir where you answer questions related to your pots of monies, yet although you have some baseline figures tucked away somewhere you still couldn't give a rough estimate as requested by the Senators? You're jut another smug imbecile trained, moulded and educated in 'Beakers beyond brain matter' methodology. Pathetic.

Video 3: Standard Beaker mumbling and head wobbling. But it was interesting how uncomfortable he got when the Pelair black box retrieval was mentioned. It looked like somebody had shoved a handful of bull-ants down the front of his 'old white apple catchers'! Ouch! It's enough to make a grown man pull his beard whiskers out!!
But it was a standard performance from aviations master accountant. Pathetic.

"Unpalatable mi mi mi for all"

[Ziggy]

Dear Senators,

Thank you.

There is a difference between knowing and understanding.
Thankfully, Our Senators are Wise enough to have acquired both.
As they carefully, de-construct history with evidence that is transparent and public.
Undisputed.

Thank you for remembering the people in the tin in the drink in the dark.
Showing Mercy and a Duty of Care towards us that were on board NGA, with an Integral Respect shown.
Acknowledging the added Mental Anguish caused by this incident spawned from Systemic failures seeping through many "levels" of political legal eagles. 
Maybe they think they know how to manage Aviation. 
Yet not Understand how to Evolve Aviation into 2015. Many of them perhaps are now shaking their Legal Wings which are becoming Unfeathered.
Exposed.
For good reason.

Thank you Senators.

May your Evolving Door remain Opened. Particularly regarding the historical learning that could have been, so much earlier in time. 
Still no learning from the exacerbation of the aberration known as VH-NGA.

In a few weeks it will be the Sixth year since the Ditch.

The "Professionals/Experts" can't even answer a simple question such as..."how many air crashes has there been from 2014-2015...wobble heads...Um, Uh...?? 
A very relevant question without an answer. Safe? Well, I think not.

Thank you Senators for being on Alert to the Systemic Problems faced within the Aviation Indusrty.

Thank you for pursuing Aviation Safety as a Priority during Question Time to the Relevant Agencies.

Displays real Knowing and Understanding of the Problems.

Questions, and there are many.

What is the Simple Safe Solution?

[Peetwo]

Bearded Buffoon read the riot act?

Way I heard it was as part of the $25,999 package, Beaker was to take scuba lessons, so as to save the tax payer money.  The notion was that if he could overcome aqua phobia, then the retrieval of CVR gear from reasonable depths could be done in a ‘cost effective’ but safe, ICAO compliant manner.  Not to mention front page photo’s of Beaker with a half peeled wet suit, clutching a six year old relic could be plastered all over ‘le’ monde’ and other salubrious publications.  Win – win and the girls would love it – Butch Beaker.

In reference to the "K" post off the Horse-pooh thread it was noted in Senate Estimates last night that yesterday the ATSB had - in the normal BBB cynical, no fanfare, 'up yours' style  - updated the PelAir reinvestigation, with details (finally) of the CVR/FDR recovery tender:

Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009

 
Investigation number: AO-2009-072
Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  

Update
Updated: 19 October 2015
On 12 June 2015, the ATSB released a Request for Tender for provision of services for the recovery of the flight recorders from VH-NGA. After an extensive evaluation process in accordance with federal government requirements, a successful tender was selected and the ATSB has entered into a contract for a recovery operation to commence on site between 3 and 8 November 2015. The recovery operation is expected to be complete by the middle of November. A further update will be released after examination of the recorders at the ATSB’s technical facilities in Canberra and assessment of whether they contain recoverable and usable data.

The previous update on 25 May 2015 outlined the nature of the other investigation activities being undertaken by the re-opened investigation. These activities are close to being completed. In addition, the re-opened investigation has conducted interviews with both flight crew and both medical crew from the accident flight.

The investigation team are now in the process of analysing the available information and they have commenced the preparation of a draft report. Given the delay in recovering the recorders and the amount of information that has been collected and analysed, it is expected that a draft report will be released to directly involved parties for comment in early 2016.

   
However if the Bearded Buffoon thought that would be enough to placate the good Senators - in particular NX & DF..  - then I am afraid he was sorely mistaken..   

That, coupled with what the Heff called the "..MH370  stuff up''..

 

..& the line of questioning coming down the pipe from the Senators on MH370 (in particular Senator Gallacher )...

...gives the impression that BBB is in potential terminal trouble & could be the first in the MH370 scapegoat line-up to be pushed in front of the bus..

The trouble is we have seen Beaker survive from similar scathing criticism before. However if I was a betting man I'd say Murky & co have already got the box measured...

Update: Hansard now released in full - Rural and Regional Affairs and Transport Legislation Committee - 19/10/2015 - Estimates - INFRASTRUCTURE AND REGIONAL DEVELOPMENT PORTFOLIO - Australian Transport Safety Bureau
    

Catching up on the Yaffa...

Yesterday courtesy the Oz Flying:

This 2015 photo shows the Westwind wreckage has not been disturbed on the ocean floor since the accident in 2009. (ATSB)



ATSB to recover Pel-Air Flight Recorder next Month
28 Oct 2015

The Australian Transport Safety Bureau (ATSB) expects to recover the Flight Data Recorder (black box) from the ditched Pel-Air Westwind in November.

The ATSB came under significant criticism for releasing their final investigation report in the November 2009 ditching off Norfolk Island without retrieving the data recorder from the wreckage. Under pressure from Minister Warren Truss and an independent audit carried out by the Canadian TSB, ATSB commissioner Martin Dolan agreed to re-open the investigation and retrieve the black box.

"I signed a contract on Thursday last week, I think it was, for the recovery services," Dolan told the Senate Estimates Committee last week. "Our current expectation is that the vessel with recovery equipment will be out there by the first week in November and we expect to complete the recovery within a week of their being at Norfolk."

Although the ATSB announced they would go after the black box in February, the actual recovery was delayed because the contract to do so had to go to tender.

Asked about the status of the re-opened investigation, Dolan provided this update.
"The information-gathering stage of the reopened investigation is essentially complete, and so the work is now going through to assess all the additional information that has been acquired to draw conclusions so that a draft report can be prepared before Christmas."

 About bloody time...   So far the VH-NGA CVR/FDR has been under the ocean 2172 days or 5 years, 11 months & 12 days. Q/ Is that a record for the longest period to recover a blackbox? The most embarrassing point is we've known all along where VH-NGA was located...


MTF..P2

[Peetwo]

Bearded Buffoon read the riot act?

Way I heard it was as part of the $25,999 package, Beaker was to take scuba lessons, so as to save the tax payer money.  The notion was that if he could overcome aqua phobia, then the retrieval of CVR gear from reasonable depths could be done in a ‘cost effective’ but safe, ICAO compliant manner.  Not to mention front page photo’s of Beaker with a half peeled wet suit, clutching a six year old relic could be plastered all over ‘le’ monde’ and other salubrious publications.  Win – win and the girls would love it – Butch Beaker.

In reference to the "K" post off the Horse-pooh thread it was noted in Senate Estimates last night that yesterday the ATSB had - in the normal BBB cynical, no fanfare, 'up yours' style  - updated the PelAir reinvestigation, with details (finally) of the CVR/FDR recovery tender:

Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009

 
Investigation number: AO-2009-072
Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  

Update
Updated: 19 October 2015
On 12 June 2015, the ATSB released a Request for Tender for provision of services for the recovery of the flight recorders from VH-NGA. After an extensive evaluation process in accordance with federal government requirements, a successful tender was selected and the ATSB has entered into a contract for a recovery operation to commence on site between 3 and 8 November 2015. The recovery operation is expected to be complete by the middle of November. A further update will be released after examination of the recorders at the ATSB’s technical facilities in Canberra and assessment of whether they contain recoverable and usable data.

The previous update on 25 May 2015 outlined the nature of the other investigation activities being undertaken by the re-opened investigation. These activities are close to being completed. In addition, the re-opened investigation has conducted interviews with both flight crew and both medical crew from the accident flight.

The investigation team are now in the process of analysing the available information and they have commenced the preparation of a draft report. Given the delay in recovering the recorders and the amount of information that has been collected and analysed, it is expected that a draft report will be released to directly involved parties for comment in early 2016.

   
However if the Bearded Buffoon thought that would be enough to placate the good Senators - in particular NX & DF..  - then I am afraid he was sorely mistaken..   

That, coupled with what the Heff called the "..MH370  stuff up''..

 

..& the line of questioning coming down the pipe from the Senators on MH370 (in particular Senator Gallacher )...

...gives the impression that BBB is in potential terminal trouble & could be the first in the MH370 scapegoat line-up to be pushed in front of the bus..

The trouble is we have seen Beaker survive from similar scathing criticism before. However if I was a betting man I'd say Murky & co have already got the box measured...

Update: Hansard now released in full - Rural and Regional Affairs and Transport Legislation Committee - 19/10/2015 - Estimates - INFRASTRUCTURE AND REGIONAL DEVELOPMENT PORTFOLIO - Australian Transport Safety Bureau
    

Catching up on the Yaffa...

Yesterday courtesy the Oz Flying:

This 2015 photo shows the Westwind wreckage has not been disturbed on the ocean floor since the accident in 2009. (ATSB)

ATSB to recover Pel-Air Flight Recorder next Month
28 Oct 2015

The Australian Transport Safety Bureau (ATSB) expects to recover the Flight Data Recorder (black box) from the ditched Pel-Air Westwind in November.

The ATSB came under significant criticism for releasing their final investigation report in the November 2009 ditching off Norfolk Island without retrieving the data recorder from the wreckage. Under pressure from Minister Warren Truss and an independent audit carried out by the Canadian TSB, ATSB commissioner Martin Dolan agreed to re-open the investigation and retrieve the black box.

"I signed a contract on Thursday last week, I think it was, for the recovery services," Dolan told the Senate Estimates Committee last week. "Our current expectation is that the vessel with recovery equipment will be out there by the first week in November and we expect to complete the recovery within a week of their being at Norfolk."

Although the ATSB announced they would go after the black box in February, the actual recovery was delayed because the contract to do so had to go to tender.

Asked about the status of the re-opened investigation, Dolan provided this update.
"The information-gathering stage of the reopened investigation is essentially complete, and so the work is now going through to assess all the additional information that has been acquired to draw conclusions so that a draft report can be prepared before Christmas."

 About bloody time...   So far the VH-NGA CVR/FDR has been under the ocean 2172 days or 5 years, 11 months & 12 days. Q/ Is that a record for the longest period to recover a blackbox? The most embarrassing point is we've known all along where VH-NGA was located...

Hitch in his weekly wrap is also very sceptical of the veracity of the ATSB PelAir reinvestigation update and the VH-NGA CVR/FDR recovery announcement:

Am I being over-cynical by smelling something predetermined in the ATSB comments about recovering the Pel-Air flight data recorder? They say they'll have it back on the surface by mid-November and have the draft report out before Christmas. That gives them, let's say, five weeks to analyse the data, determine the impact of the pilots' actions and blend it all into their draft report. The only way a government bureaucracy can do that in such a short time is if most of the report, including the conclusions, is already written. Now, we have to give the ATSB this: they did say that they thought the data from the FDR would do nothing to change their view of what happened. That could be why retrieving the FDR is one of the last things happening in this investigation sequence rather than one of the first. I truly hope I am being over-cynical, because another white-wash report will do nothing to ease the pain of those involved.

That's the problem anything that comes out of the Dolan led bureau these days will always be subject to cynical suspicion.. 


MTF..P2

[Kharon]

Well done Hitch.

Nice summary from Hitch, again.  He must have developed a liking for Choc frogs.

Hitch – “That gives them, let's say, five weeks to analyse the data, determine the impact of the pilots' actions and blend it all into their draft report.”

The report is running behind and delayed, the New year for the DIP – says beaker.  So it it will be nearer Easter before the ‘public’ get to see it.   One only needs to watch the first five minutes of ATSB part III (P2 #64) to realise that Beaker still, after all that has occurred is taking the Mickey out of the Senators.  Reluctantly the CVR is to be retrieved, but watch for the give away signals as the ‘signing’ of the contract is mentioned, classic Beaker high five moment.  If it were Poker, you’d know he has a royal flush at least.  

Hitch – “The only way a government bureaucracy can do that in such a short time is if most of the report, including the conclusions, is already written.

Watch again after Fawcett sets out the state of play – Beaker knows, full well, that the situation is under control and no matter how much the Senators want probity, the die is cast.  ATSB have complied, technically they have, nothing will change the original will be massaged a little, polished and thrown down as a gauntlet challenging the Senators to prove otherwise.  

Hitch – “Now, we have to give the ATSB this: they did say that they thought the data from the FDR would do nothing to change their view of what happened.”

Good catch, now they intend to prove that.  That CVR data could identify that the aircraft was forced down by malignant aliens in a flying saucer, with pictures and it will still be solely the pilots fault.  Hell, CASA could find a new line to prosecute – failure to give way or some such bullshit to add to a sorry tale.

Hitch – “That could be why retrieving the FDR is one of the last things happening in this investigation sequence rather than one of the first.

Hitch, there’s only about 150 investigators I can call on who agree with you.  Whether malice aforethought, ignorance, arrogance or plain old fashioned parsimony; Beaker and his masters never wanted to see that CVR.  We can only guess why and hope that the data is not corrupt.  It may not solve the problems which led to the event, but it will clear up exactly what was occurring in that cockpit.  I for one would like to know, why? Well it is one corner of the investigation which, to my mind has been dark and avoided by all – both sides – why?

Hitch – “I truly hope I am being over-cynical, because another white-wash report will do nothing to ease the pain of those involved.

Sorry mate, we have in the Tim Tam box, two reports which were drafted when the recovery was first announced.  The one closest to the ‘new’ ATSB report wins the pot.  The outcome was always predictable, it is now only a matter of deciding which of our two candidates reports most closely matches yet another predetermined outcome.

Selah.

[Peetwo]

ATSB - Can it be saved?

Here we are approaching the sixth anniversary of the PelAir, VH-NGA, Norfolk Is ditching. However besides some rhetoric & false promises from the bureau executive management, there has been no visible improvement that would suggest the ATSB is back to ICAO Annex 13 (& now 19) ToRs:

Annex 13 - 3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.

Annex 19 (Attach A) - 1.3 Accident and incident investigation


The State has established an independent accident and incident investigation process, the sole objective of which is the prevention of accidents and incidents, and not the apportioning of blame or liability. Such investigations are in support of the management of safety in the State. In the operation of the SSP, the State maintains the independence of the accident and incident investigation organization from other State aviation organizations.

In fact recent evidence would suggest that the bureau is in fact going backwards in terms of the recommended reforms suggested by the Senate AAI inquiry, the TSBC review & the ASRR reports.

NX -"..The details of the ditching and subsequent report are complex and technical. However, the core of the issue is that the ATSB produced a report into the ditching over 33 months after the incident that, contrary to world’s best practice and the ATSB’s own standards, did not even touch on the systemic or regulatory environment in which the pilot was operating. Instead, it focussed primarily on the pilot’s actions. It did not examine the organisation for which the pilot was working, or the systems, procedures or environment in that organisation. This is despite the fact that a CASA Special Audit of Pel-Air after the ditching discovered serious regulatory breaches, and an internal CASA report (the Chambers Report) found significant failures in CASA's oversight of the operator. While neither of these documents were provided to the ATSB in a timely manner (the Chambers report was not released to them until after the inquiry had commenced), the ATSB's investigation should have discovered these problems. That there was no indication of this in the report is a serious concern..."

Once again reflecting on para 1.6 of the Senator Xenophon additional comments (above) to the Senate Inquiry - Who guards the guards themselves? - it is plain that not much has changed..

A classic example is with the still ongoing Mildura Fog incident -  Weather related operational event involving B737s VH-YIR and VH-VYK at Mildura Airport, Victoria on 18 June 2013

After more than 2 years with several obviously serious latent safety issues yet to be effectively risk mitigated or indeed safety recommendations issued to address, this farce of an investigation is IMO a monumental embarrassment..

However we should not forget that the obfuscation & top-cover by the bureau is coming from the executive management & commission. The TSIs on the coalface continue to a tough job in sometimes very trying conditions...

In recognition of that Tinkicker caught an excellent article off the Conversation publication, which describes in great detail the process of a properly conducted Annex 13 AAI:

How air accident investigators turn disaster into a way of saving lives
November 5, 2015 1.16am AEDT
 Graham Braithwaite
Author

Director of Transport Systems, Professor of Safety & Accident Investigation, Cranfield University

Disclosure statement
Graham Braithwaite does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.

The Conversation is funded by CSIRO, Melbourne, Monash, RMIT, UTS, UWA, ACU, ANSTO, ANU, Canberra, CDU, CQU, Curtin, Deakin, ECU, Flinders, Griffith, the Harry Perkins Institute, JCU, La Trobe, Murdoch, Newcastle, UQ, QUT, Swinburne, Sydney, UNDA, UNE, UniSA, UNSW, USC, USQ, UTAS, UWS, VU and Wollongong.
Republish this article

Throughout aviation’s comparatively brief history, properly investigating the causes of accidents has been essential to improving flight safety, to the point that aviation is one of the safest ways to travel. Looking at the pictures of debris scattered across many square miles of Egyptian desert, or Ukrainian sunflower fields, or floating at sea, the fact we’re able to draw useful lessons from such destruction is testament to the efforts of air accident investigators worldwide. How do they do it?

Aviation rules and practices are governed by the International Civil Aviation Organisation (ICAO, a UN agency) and through a document known as Annex 13 to the Convention on International Civil Aviation, under which all signatory nations are obliged to investigate accidents occurring within their borders. Like a coroner’s court inquest, the focus is on learning lessons rather than building a case against a perceived guilty party.

When notified of an accident, the national investigation agency deploys a team to the site – in the UK this is the Air Accidents Investigation Branch (AAIB) of the Department for Transport. Generally the team includes three investigators: one with a pilot background, one with an engineering background, and another specialising in flight data recorders.

[/url]
Investigators getting their hands dirty.

At the scene of the accident the investigators’ first vital task is to assess which evidence may be perishable. What could be lost? This could be snow and ice, or witness recollections. Other evidence that can be altered through accident or design must also be prioritised and recorded – for example the position of control switches or wreckage, and documentation.

This is quite a task in itself, and investigators usually start with a rational overall assessment of the accident site. Sometimes there may be more than one area of interest – for example where the aircraft breaks up in flight as happened in the recent crash in Egypt or MH17, and where debris is scattered over many square miles. In other cases, evidence may lie at the departure airport or at the aircraft’s home maintenance hangar. Experienced investigators will say that they let the accident site tell the story, taking in the full picture rather than immediately focusing on the forensic detail.

Letting the evidence speak for itself
The investigator’s approach is critical. They need to be led by the evidence at all times, and mindful that things are rarely as they first appear. This is one (of many) reasons why those in the investigation business will often shake their fists at so-called experts whose speculation and hunches fill initial news reports after a crash. A good investigator sets out to test hypotheses with the evidence, rather than collect evidence to support a theory.
This is also the reason why, sometimes, investigations can take many years to complete.

The ICAO suggests one year as a target, but many take longer – the complex investigation into [url=http://www.tsb.gc.ca/eng/medias-media/fiches-facts/a98h0003/sum_a98h0003.asp]Swissair Flight 111 which crashed over Nova Scotia took five years to complete, for example.

The physical evidence that remains is of great importance and is generally subjected to various types of imaging in situ, such as photography, laser scanning (LiDAR), and airborne or satellite imaging. This is especially important if the accident site is remote or scattered, as the pattern of the wreckage and how it is distributed is as important as the debris itself. Minor details such as dents and paint scrapes all provide the investigators with details to help decipher the flight’s last moments.

Where and how the wreckage falls is as important as the debris itself. Igor Kovalenko/EPA

Black boxes
In addition to physical evidence is the in-flight record of the aircraft’s systems – the “black box” comprised of the Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR). These amazing devices record the last two hours of sound on the flight deck and many hours of essential flight data such as control inputs, heading, speed, altitude, and the status of systems such as engines and cabin air supply.

However, they are only as good as the data that feeds them and those who interpret them. If the data going in is garbage then the recorder will not help. It’s also important to realise that they only record what happened, but not why – this is especially important when trying to understand the human element of accidents, for example the Germanwings crash in the Alps.

Technological testing
Investigation teams can grow very large, with investigation teams from the country in which the aircraft was manufactured, or operated, or designed all having a right to participate. Technical advisers are brought on board for their specialist knowledge or facilities: engine or airframe manufacturers, research laboratories (such as QinetiQ), or universities.

For example, Rolls-Royce use X-ray tomography to examine damaged engines, looking for signs of metal fatigue or contamination before they are stripped down to avoid losing precious evidence during dis-assembly. Simulations often play a role: Cranfield Impact Centre was asked to examine the Boeing 777 crash at Heathrow in 2008 on behalf of the AAIB using computer and physical simulations. This was done under close supervision of the investigators in order to maintain the investigation’s independence.

Often the best way is to physically piece together the wreckage. In doing so, it’s possible to see how the structure broke apart, or to check for residues of explosives or tell-tale impact marks. This task is much easier when reconstructed in three dimensions rather than looking at individual pieces of metal laid out on a hangar floor. The clues gleaned from this process can be corroborated against those from elsewhere, such as post-mortem results of the occupants, closer forensic examination of the wreckage, or flight recorder or radar data.

Pulling it all together
Usually the team has been assembled at zero notice from organisations selected purely by the circumstances of the accident. There is huge pressure on the team – from society and the commercial airline operators and manufacturers who need to know the safety implications as soon as possible. The ability of the investigator in charge to manage the process, by avoiding media leaks and keeping all involved on-side for example, is key.

It’s rare an investigation pivots on a single, Hollywood-style eureka moment. Instead it comes from the un-glamorous, methodical and painstaking work of sifting through a jigsaw of evidence, some of which will be wrong or contradictory. Witness statements, for example, are frequently not entirely accurate. The challenge for the investigators is to carefully analyse how the pieces fit together, and whether it’s possible to collect further evidence or conduct tests that fill in the gaps to prove or disprove a theory.

Only with thorough analysis can the team piece together the sequence of events, understand why they occurred, and what changes should be recommended as a consequence. Sometimes accidents occur because of management decisions made many years before, or even less tangible factors like safety culture among flight or maintenance crew - these are difficult problems to pinpoint.

Perhaps the least exciting aspect of the investigation is the most important – that of writing up the final report. It must be written with care, without allocating blame and knowing that it will be read by both relatives and regulators. If a poorly worded recommendation is rejected then all their hard work may be in vain, so each statement must be thoroughly supported. But good regulators know well to act on sound recommendations, and it’s largely because this system works so well that aviation is as safe as it is today.

   
Top stuff Prof Braithwaite, no further comment required...P2
 
     

[Peetwo]

Sunday Ramble - Beyond the pale  

For the probity of the ATSB one of the most shameful decisions (or non-decisions) of DPM Truss was to appoint Martin Dolan for a further 2 years as Chief Commissioner. Then to stand by his man after the TSBC review is quite simply beyond the pale..

From NX Media Release 3rd December 2014: Aviation safety failure

..Senator Xenophon called for the removal of head of the Australian Transport Safety Bureau (ATSB), Martin Dolan, and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and the Civil Aviation Safety Authority (CASA)...

...“The Canadian report and the Minister’s statements are further testament to the ATSB’s incompetence. The Minister is right to call for a re-opening of the investigation, but he’s wrong to ask the ATSB to do it. It needs to be done independently,” said Nick...

Well IMO that decision to stand by this Muppet is now coming home to roost, especially when you review the latest disgusting missive by BBB in the ATSB Annual Report. See P7 post here off the SMH thread...

However the self-flagellation, self-aggrandisement of BBB gets sickeningly worse in his summary of aviation investigations:

Aviation

During the year we completed 40 aviation investigations and more than 100 short factual investigations.

The most significant of these was the crash of a Robinson R44 helicopter at Bulli Tops on 21 March 2013 (AO-2013-055). This, as well as two previous similar accidents involving R44 helicopters, highlighted the danger of rigid fuel tanks in low-impact helicopter crashes, where post-impact fires may make otherwise survivable accidents deadly. We confirmed this trend with detailed statistical analysis of similar accidents in Australia and the US over a 10-year period.

While the Civil Aviation Safety Authority (CASA) had recommended that owners and operators implement the manufacturer’s service bulletin recommendation to replace the fuel tanks with bladder-type tanks that would improve resistance to post-impact fuel leaks, it was clear that they would be unlikely to meet the 30 April 2014 deadline.
Accordingly, the ATSB recommended that CASA mandate the requirement by the due date. As a result, all R44 helicopters in Australia are now compliant.

Following this action, other safety authorities in South Africa, New Zealand and Europe have also mandated the change have also mandated the change. The ATSB has issued safety recommendations to the US Federal Aviation Administration that they also take action to mandate fitting of bladder-type fuel tanks. The outcome of this investigation illustrates the importance of our investigations and the far-reaching influence safety investigations can have in ensuring transport safety for all travellers, not only those in Australia or our immediate region...

   
You might remember this (also off the SMH - post#23) back in early June:   

In case you needed anymore proof that the whole point of Dolan being the front man in the Bulli Tops media release, is purely a disgusting PR sham to grab the limelight away from recent bad press, here it is...FFS :

Tweet from ATSB this AM:

@atsbinfo warning on helicopter fuel tanks may lead to worldwide aviation safety changes http://www.illawarramercury.com.au/story/3126661/

  
And this was the article from the Illawarra Mercury (where the last sentence (in bold) will be conveniently overlooked by Beaker & the ATSB):

Bulli Tops helicopter crash sparks global warning

By MICHELLE WEBSTER
June 4, 2015, 9 p.m.

A horrific helicopter crash at Bulli Tops which claimed the lives of four former CSIRO scientists in March, 2013, may lead to worldwide aviation safety changes...

California-based Robinson Helicopter Company issued a service bulletin to R44 operators in December, 2010, telling them to swap to flexible fuel tanks.

Some on here will remember that at Budget Estimates in May 2013 (i.e. 2 months after the tragic Bulli tops accident), the matter of the R44 post impact fire accidents were the subject of Senate questioning. Here is a copy of a post of mine off the UP from that time:

Yep the list is growing and the stench is rising!

--------------------------------------------------------------------------------

You can add the Cousin's to that list...remember this from sub16:

“We have been to Martin Dolan Chief Commissioner ATSB, Albanese, John McCormick, Local Member John Castrilli - who did write a letter to CASA on our behalf but that was it! John McCormick insulted us in his response stating that "CASA is unaware of any other accidents involving this company’s aircraft". Oh My God how insulting to our intelligence. So in their eyes Kenny's Mob have never been involved in other incident!

How many fatalities does a Company need to have to be anything recorded as an ACCIDENT! At the inquest the CEO of Heliworks was questioned about his Statutory Declaration and had he completed - he disclosed he did not complete it and the Company had told him what to write! How could that be admissable in a court of law?

They were aware that this cowboy operation existed out at the Bungles but once again NO ONE would do a thing to stop them...............

It took 2 yrs 7 mths after the accident for the inquest to be held and we did not get the final report until a further 6 months!! Over 3 years!!”

Then

“Well we had our inquest which was an absolute joke and embarrassment for the fact that so many documents were not produced / lost / created etc and no one did a thing about it. Our Coroner Ms Fricker left a lot to be desired and the fact that in the 2 years 7 months not one person in the court room excluding us had even visited the accident site or gone out to witness just what happens out there. We came away just blown away with the fact that so many things were dismissed/ allowed/undisclosed and were allowed to be.

That smell of money I think well and truly came into play!!!
I personally lost all respect for our government representatives, law, safety authorities after sitting in that court room for 5 days and listened to excuses on their behalf...instead of reasons to rectify and was horrified after the evidence given that it was declared and accident.

As I said in court this was an Accident waiting to happen and will occur again!!The coroner in her report even noted the number of helicopter accidents just since the inquest - approx 4 month....and not one recommendation was handed down. She used the words like Breached and Failed to comply in her report and yet not one
recommendation.”

Carolyn Cousins. (mother of Jessica Cousins) Slingair Robinson 44 Bungle Bungles 14

September 2008 4 fatalities

Although according to Beaker this accident was a high-energy impact:

Mr Dolan: There had been a number of post-crash fires associated with R44 helicopters. In the vast majority of those cases they represented high-energy impacts, which is to say accidents that were unlikely to have been survivable and which would have led to a post-crash fire in almost any helicopter.

Senator XENOPHON: So you are saying that the retrofitting would not have made any difference?

Mr Dolan: That would be our general assessment.

Senator XENOPHON: Take it on notice, because I have a few other matters to raise. You are saying that, from a causation point of view, even retrofitting the helicopters with that protective bladder, it still would have been a fatal accident?

Mr Dolan: On the facts that were available to us. We are not aware of any previous to Cessnock. I do not think we are aware of any of the low-energy collisions leading to that sort of thing. There were, as you say, a number of high-energy collisions that would have led to a ruptured fuel tank in any helicopter and therefore a great likelihood of a post-crash fire. Those are the sorts of accidents that generally are not survivable.

But on the evidence in the bureau report it would appear that there was a strong possibility the pilot at least survived the crash impact only to be overcome by the post impact fire, from the report:

Medical and pathological information
The post-mortem examinations for all occupants of the helicopter described varying degrees of injuries consistent with the high vertical velocity impact. All sustained extensive thermal injury.

The pilot’s post-mortem report indicated that he was found ‘...a slight distance from the damaged aircraft.’

You will notice that the post-mortem didn't appear to explore how the victims died i.e. did they succumb to their impact injuries or the 'extensive thermal injuries'. Nor was IMO the post-survivability issues properly explored by the ATSB. It was almost as if the ATSB accept that if a chopper comes (in particular a Robbo) down hard it will inevitably burn!

Yes 004 it will be interesting to watch and I bet there will be a couple of interested Senators tuned in as well..given the QONs outstanding on the subject of post-impact fires and R44s

Here's the links for the high energy post-impact fire fatalities to which Senator X refers:
http://www.atsb.gov.au/media/1533519/ao2008062.pdf

http://www.atsb.gov.au/media/1361537/aai...79_001.pdf

http://www.atsb.gov.au/media/24556/aair2...46_001.pdf

And here is a link for the report from the Jaspers Brush tragedy - AO-2012-021 - that included these two safety issues:

Fitment of rubber, bladder-type fuel tanks to R44 helicopters

And in ICAO Annex 13 Ch 6 under Safety  Recommendations  it is stated...

"..6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO..."

So what is the ATSB excuse for sitting on these SRs until now (over two years after the fact)?? No this is just another cynical attempt to gain credibility where none is due..
FFS get rid of the Muppet.    

I guess it is not surprising then that BBB is hanging his hat on the Bulli Tops R44 crash investigation but I very much contend the veracity of most of the rest of his statement regarding the safety risk mitigation SR and its impact/recognition by other State NAAs/AAIs, in particular the FAA.

The following is an article from off Bloomberg Business, which perfectly highlights what I mean:

The FAA Wants New Helicopters to Have Crash-Resistant Fuel Tanks

Alan Levin AlanLevin1
October 21, 2015 — 8:00 PM AEDT Updated on October 22, 2015 — 6:25 AM AEDT

• Reinforced fuel tanks would decrease fires after accidents
  
• Regulators ask industry panel to study broad safety changes
  

U.S. aviation regulators plan to require all newly built helicopters to have crash-resistant fuel tanks to cut the risks of leaks and deadly fires after accidents as part of the broadest effort in decades to improve rotor-aircraft safety.

The Federal Aviation Administration asked an advisory committee to draft new regulations requiring the technology, according to a Sept. 28 letter sent to the National Transportation Safety Board and posted on the agency’s website.

That marks a significant shift on a controversial safety issue that has been linked to more than 200 civilian deaths since 1994. The U.S. Army has cut casualties from fires after helicopter crashes with the use of bladder-like fuel tank linings developed during the Vietnam War, but some operators and manufacturers argued that such technology was too expensive and would hamper operations.

“It is going to be extremely difficult and expensive to figure out how to incorporate it into an existing design,” Walter Desrosier, the vice president for engineering and maintenance at the General Aviation Manufacturers Association trade group, said in an interview.

The FAA asked the industry panel, called the Aviation Rulemaking Advisory Committee, to explore ways to better protect helicopter occupants from crashes, according to an Oct. 8 letter. It was spurred by a recent study showing better protections would save lives, according to the FAA letter. The agency also is asking for a review of other safety measures, including requiring seats that don’t break loose in accidents and structural changes to prevent occupants from being crushed.

New Standards
The action was spurred by emerging data on helicopter crashes and how to prevent them in the future, FAA Administrator Michael Huerta said in an interview Wednesday. “What we want to do is take advantage of what more do we know,” Huerta said.

In the 1980s and 1990s, the FAA adopted helicopter safety standards for new designs. Since then, however, only 16 percent or fewer helicopters sold have the protections because manufacturers mainly produce aircraft based on older designs.

“This approach has resulted in a very low incorporation rate of occupant protection features into the rotorcraft fleet, and fatal accidents remain unacceptably high,” the FAA said.

While the helicopter industry supports reviewing whether new standards make sense, it hasn’t endorsed any specific measures, Desrosier said. Requiring fuel-tank upgrades may cost manufacturers millions of dollars, an expense that wouldn’t justify whatever benefit it creates, he said.

One option may be to create a streamlined protection system that would be cheaper to install on existing models, he said.

UT, Airbus
GAMA represents helicopter makers including United Technologies Corp.’s Sikorsky Aircraft division, Airbus Group SE’s Airbus Helicopters Inc. and Textron Inc.’s Bell Helicopter. GAMA members delivered 971 new helicopters last year, according to the group’s annual statistical report.

The Helicopter Association International, a trade group representing fleet operators, supports the FAA’s effort though it hasn’t endorsed changes to fuel tanks or other specific measures, said Chris Dancy, a spokesman. The group will work on the advisory committee, he said.

Safer fuel tanks were developed by the military in the 1960s in response to the high number of casualties in Vietnam after helicopters caught fire in the aftermath of crashes that were otherwise survivable.

Companies including Robertson Fuel Systems LLC of Tempe, Arizona, have built such tanks for military aircraft and ground vehicles, as well as race cars, according to company founder S. Harry Robertson. Their system, known as “Robbie Tanks,” work by preventing leaks even after being pierced by bullets or fractured by an impact.

The safety board on July 23 urged the FAA to impose stricter standards. The FAA agrees with the NTSB on the need to upgrade fuel tanks and has started the rulemaking process, the FAA’s Huerta wrote in the September letter.

Wichita Crash

The NTSB’s July recommendation was prompted by an Oct. 4, 2014, helicopter accident in Wichita Falls, Texas. Surveillance video that captured the crash showed a flight nurse and paramedic survived the impact, but died when fuel spilled and ignited, according to the NTSB.

From 1994 to 2013, there were 135 helicopter accidents in which fire broke out after impact, resulting in 221 deaths and 37 serious injuries, according to NTSB. Of those crashes, only three had crash-resistant fuel systems.

After the U.S. Army began requiring fuel protections in the 1960s, it saw a 75 percent decrease in injuries and zero fatalities attributed to post-crash fires, according to the NTSB letter. The letter didn’t specify the years when the decrease took place or how many deaths there were prior to the requirement taking effect.

The FAA didn’t set a deadline for when it would complete its new regulations. It must first draft the rule and then allow the public and industry to comment.

 Hmm...didn't see any mention of the ATSB's belatedly issued SR or the Bulli Tops FR...

Perhaps it gets a mention in the NTSB Wichita FR - NTSB Identification: CEN15FA003 ...err nope  

A how to - courtesy the NTSB.

Oh well at least we do get a perfect example of the power of a well worded safety recommendation - Safety Recommendation A-15-012 

TO THE FEDERAL AVIATION ADMINISTRATION: Require, for all newly manufactured rotorcraft regardless of the design’s original certification date, that the fuel systems meet the crashworthiness requirements of 14 Code of Federal Regulations 27.952 or 29.952, “Fuel System Crash Resistance.”

Reply:

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) agrees with this recommendation and has started the rulemaking process by sending a tasking statement to the Aviation Rulemaking Advisory Committee. Any resulting part 27 or part 29 rulemaking the FAA proposes would require that we give public notice of our intent to implement a rule change and consider any comments to our proposal. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by September 30, 2016.

MTF..P2

[Peetwo]

Finally after 2185 days -

From the O&O thread

PelAir - 'Lest we forget' Part III - Six years on and the ATSB is still a basket case..

Courtesy Ben Sandilands (Planetalking blog):

Six years on, ATSB about to recover Pel-Air flight data recorder

Ben Sandilands | Nov 09, 2015 3:30PM |

In another triumph of administrative efficiency, diligence and focus the Australian Transport Safety Bureau or ATSB, is poised, after almost six years, to recover the flight recorder from the Pel-Air Westwind corporate jet that was ditched in the sea near Norfolk Island on 18 November 2009.

The small jet had intended to refuel at Norfolk Island on its way from Apia to Melbourne as part of a medical charter flight, but had insufficient fuel on board to divert to an alternative airport when despite four missed approaches it was unable to land because of deteriorated weather conditions.

All six people on board were rescued by an island fishing boat and in the course of its original and since discredited investigation into the accident the ATSB decided not to recover the recording device, which is less sophisticated than those on larger jets, and of a design which in some quarters is said to be prone to medium term salt water corrosion.

The decision of the ATSB to blame everything on the pilot, and not recover the flight recorder led to a prolonged and continuing controversy.  A peer review of the ATSB’s conduct of the first inquiry by the Transportation Safety Board of Canada found (for those who managed to read all of it) that not all of the relevant information available to the ATSB may have been taken into account, and referenced internal frustrations and divisions within the ATSB investigation.

A review of that report can be read here.

Damning review of ATSB Pel-Air investigation released

Ben Sandilands | Dec 02, 2014 12:44PM |

Memo Tony Abbott and Warren Truss. Second rate isn’t good enough in air safety investigations, and the Canadian peer review of the ATSB re Pel-Air makes us look very grubby.

The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.

This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.

The report also casts light on internal frustrations and divisions within the ATSB investigation.

It summarises some of those matters as follows.

3.10 Findings from the TSB review of the Norfolk Island investigation

1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
   
2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
   
3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
   
4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analyzed.
   
5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
   
6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
   
7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
   
8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
   

If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised report up,  as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.

This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.

The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation.

This is just a part of what the TSBC review says on such matters.

The Minister supposed to be looking after aviation, Warren Truss, has previously parrotted lines written for him by his department that there is no value in re-opening or replacing the final report of the Pel-Air investigation.

This embrace of second rate by a Minister supposed to uphold fairness and excellence in aviation safety reporting is unworthy.

The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.
Second rate isn’t good enough for Australia.

The ATSB was subsequently ‘invited’ by the Deputy PM and minister responsible for aviation, Warren Truss, to revisit its report, which the agency after a delay removed from its web site pending its in effect, being redone.

Recovering the flight recorder is part of this process.

The dysfunctional manner in which the prolonged ATSB inquiry was conducted was laid bare in the peer review by the TSBC although this was only apparent on a full reading of that document rather than in relying on the summaries offered by the Department of Infrastructure which is responsible for both the safety investigator and the air safety regulator CASA.

The crux of the Pel-Air controversy is that the pilot was framed by the ATSB and CASA while the safety regulator improperly withheld an internal report which found gross failures on its part to correctly oversight or remedy what was found to have been serious safety deficiencies by the operator.

One of the critical matters raised by the controversy is the integrity of the ATSB in relation to the first Pel-Air accident investigation report, including its disinterest in that suppressed internal CASA review of its own performance.

That internal report, known as the Chambers Review, concluded that had CASA done its job the accident might not have happened.

The ATSB website has been updated on the recovery operation.

The image below from the ATSB shows what the wreckage looked like in March this year.

Will we forget? Not bloody likely..

Well apparently the VH-NGA CVR/FDR was recovered yesterday...

Here is the update from the ATSB investigation page:

Aviation safety investigations & reports


Investigation title - Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009
 
Investigation number: AO-2009-072

Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  
  

Update
Updated: 12 November 2015

During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra. The part numbers and serial numbers of the recorders agree with the maintenance documentation for the aircraft. The recovery and storage of the recorders was witnessed by an officer of the Australian Federal Police. Examination of, and data recovery from, the recorders is expected to commence during the week of 16 November 2015.
 
 
Updated: 9 November 2015

In March this year, an underwater survey of the Pel-Air aircraft wreckage was conducted by the ATSB with the assistance of NSW state and federal police officers. The survey was conducted to establish the condition of the wreckage and to assess a viable means of recovering the flight recorders. Subsequently, a commercial marine salvage company, the Pacific Marine Group, was selected through a tendering process to contract with the ATSB to complete the operation. The salvage vessel, PMG Pride, is currently underway from her home port of Townsville and is expected to arrive at Norfolk Island in the next few days.
Early this week investigators from the ATSB, along with an officer from the Australian Federal Police will be working together with the project team from Pacific Marine Group to raise the Pel-Air wreckage and recover the flight recorders. The recorders will be transported back to the ATSB headquarters in Canberra for download and analysis. The data on the ‘black boxes’ will be used to further assist the ATSB investigators understand the sequence of events of the accident. 

The ATSB requests that all local vessels remain away from the Pel-Air wreckage site throughout next week. The PMG Pride will be at anchor and there will be divers and salvage equipment in the water....  

As "V" said on twitter - .."Interesting times ahead"..


MTF..P2

[Peetwo]

Finally after 2185 days -

From the O&O thread

PelAir - 'Lest we forget' Part III - Six years on and the ATSB is still a basket case..

Courtesy Ben Sandilands (Planetalking blog):

Six years on, ATSB about to recover Pel-Air flight data recorder

Ben Sandilands | Nov 09, 2015 3:30PM |

In another triumph of administrative efficiency, diligence and focus the Australian Transport Safety Bureau or ATSB, is poised, after almost six years, to recover the flight recorder from the Pel-Air Westwind corporate jet that was ditched in the sea near Norfolk Island on 18 November 2009.

The small jet had intended to refuel at Norfolk Island on its way from Apia to Melbourne as part of a medical charter flight, but had insufficient fuel on board to divert to an alternative airport when despite four missed approaches it was unable to land because of deteriorated weather conditions.

All six people on board were rescued by an island fishing boat and in the course of its original and since discredited investigation into the accident the ATSB decided not to recover the recording device, which is less sophisticated than those on larger jets, and of a design which in some quarters is said to be prone to medium term salt water corrosion.

The decision of the ATSB to blame everything on the pilot, and not recover the flight recorder led to a prolonged and continuing controversy.  A peer review of the ATSB’s conduct of the first inquiry by the Transportation Safety Board of Canada found (for those who managed to read all of it) that not all of the relevant information available to the ATSB may have been taken into account, and referenced internal frustrations and divisions within the ATSB investigation.

A review of that report can be read here.

Damning review of ATSB Pel-Air investigation released

Ben Sandilands | Dec 02, 2014 12:44PM |

Memo Tony Abbott and Warren Truss. Second rate isn’t good enough in air safety investigations, and the Canadian peer review of the ATSB re Pel-Air makes us look very grubby.

The independent peer review of the ATSB by its Canadian counterpart the TSBC finds serious issues with the methodologies and processes it followed before publishing its much criticised final report into the Pel-Air crash near Norfolk Island in 2009.

This might not of course, be what the ATSB or the minister responsible for aviation, Warren Truss, might say, but the closely argued Canadian report, if read in its detail, makes it clear that the Australian safety body failed at many levels to collect and process the necessary information.

The report also casts light on internal frustrations and divisions within the ATSB investigation.

It summarises some of those matters as follows.

3.10 Findings from the TSB review of the Norfolk Island investigation

1. The response to the Norfolk Island investigation report clearly demonstrated that the investigation report published by the ATSB did not address key issues in the way that the Australian aviation industry and members of the public expected.
   
2. In the Norfolk Island investigation, the analysis of specific safety issues including fatigue, fuel management, and company and regulatory oversight was not effective because insufficient data were collected.
   
3. The ATSB does not use a specific tool to guide data collection and analysis in the area of human fatigue.
   
4. Weaknesses in the application of the ATSB analysis framework resulted in data insufficiencies not being addressed and potential systemic oversight issues not being analyzed.
   
5. The use of level-of-risk labels when communicating safety issues did not contribute to advancing safety, and focused discussion on the label rather than on the identified issue and the potential means of its mitigation.
   
6. A misunderstanding early in the investigation regarding the responsibilities of CASA and the ATSB was never resolved. As a result, the ATSB did not collect sufficient information from Pel-Air to determine the extent to which the flight planning and monitoring deficiencies observed in the occurrence existed in the company in general.
   
7. Ineffective oversight of the investigation resulted in issues with data collection and analysis not being identified or resolved in a timely way.
   
8. The lack of a second-level peer review in the Norfolk Island investigation meant that improvements to the analysis and conclusions stemming from the peer review were not incorporated into the report.
   

If the ATSB or the Minister thinks this supports a decision to leave this second rate, and severely flawed and grossly unfair and compromised report up,  as Australia’s contribution to the safety lessons arising from the world’s first ever ditching of a Westwind corporate jet, then the more fool them.

This is a national embarrassment, and not good optics when we are managing at Kuala Lumpur’s behest, the ocean floor search for missing Malaysia Airlines flight MH370.

The government has previously ignored a highly critical Senate Committee report into these matters, including its adverse findings as to the credibility of the ATSB’s chief commissioner Martin Dolan, and the discovery of the questionable suppression of a CASA audit of the Pel-Air operation, a matter the Canadian TSB says was felt throughout the ATSB investigation.

This is just a part of what the TSBC review says on such matters.

The Minister supposed to be looking after aviation, Warren Truss, has previously parrotted lines written for him by his department that there is no value in re-opening or replacing the final report of the Pel-Air investigation.

This embrace of second rate by a Minister supposed to uphold fairness and excellence in aviation safety reporting is unworthy.

The Canadian review, no matter how much the government tries to massage it, exists in a detail which is damning as to the conduct and processes followed by the ATSB.
Second rate isn’t good enough for Australia.

The ATSB was subsequently ‘invited’ by the Deputy PM and minister responsible for aviation, Warren Truss, to revisit its report, which the agency after a delay removed from its web site pending its in effect, being redone.

Recovering the flight recorder is part of this process.

The dysfunctional manner in which the prolonged ATSB inquiry was conducted was laid bare in the peer review by the TSBC although this was only apparent on a full reading of that document rather than in relying on the summaries offered by the Department of Infrastructure which is responsible for both the safety investigator and the air safety regulator CASA.

The crux of the Pel-Air controversy is that the pilot was framed by the ATSB and CASA while the safety regulator improperly withheld an internal report which found gross failures on its part to correctly oversight or remedy what was found to have been serious safety deficiencies by the operator.

One of the critical matters raised by the controversy is the integrity of the ATSB in relation to the first Pel-Air accident investigation report, including its disinterest in that suppressed internal CASA review of its own performance.

That internal report, known as the Chambers Review, concluded that had CASA done its job the accident might not have happened.

The ATSB website has been updated on the recovery operation.

The image below from the ATSB shows what the wreckage looked like in March this year.

Will we forget? Not bloody likely..

Well apparently the VH-NGA CVR/FDR was recovered yesterday...

Here is the update from the ATSB investigation page:

Aviation safety investigations & reports


Investigation title - Ditching of Israel Aircraft Westwind 1124A aircraft, VH-NGA, 5 km SW of Norfolk Island Airport on 18 November 2009
 
Investigation number: AO-2009-072

Investigation status: Active
 

• Update
  
• Re-opened
  
• Photos
  
• Safety Issues
  
  

Update
Updated: 12 November 2015

During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra. The part numbers and serial numbers of the recorders agree with the maintenance documentation for the aircraft. The recovery and storage of the recorders was witnessed by an officer of the Australian Federal Police. Examination of, and data recovery from, the recorders is expected to commence during the week of 16 November 2015.
 
 
Updated: 9 November 2015

In March this year, an underwater survey of the Pel-Air aircraft wreckage was conducted by the ATSB with the assistance of NSW state and federal police officers. The survey was conducted to establish the condition of the wreckage and to assess a viable means of recovering the flight recorders. Subsequently, a commercial marine salvage company, the Pacific Marine Group, was selected through a tendering process to contract with the ATSB to complete the operation. The salvage vessel, PMG Pride, is currently underway from her home port of Townsville and is expected to arrive at Norfolk Island in the next few days.
Early this week investigators from the ATSB, along with an officer from the Australian Federal Police will be working together with the project team from Pacific Marine Group to raise the Pel-Air wreckage and recover the flight recorders. The recorders will be transported back to the ATSB headquarters in Canberra for download and analysis. The data on the ‘black boxes’ will be used to further assist the ATSB investigators understand the sequence of events of the accident. 

The ATSB requests that all local vessels remain away from the Pel-Air wreckage site throughout next week. The PMG Pride will be at anchor and there will be divers and salvage equipment in the water....  

As "V" said on twitter - .."Interesting times ahead"..

Courtesy PT..

ATSB now has only one set of black boxes lost at sea

Ben Sandilands | Nov 12, 2015 9:28PM |


The rear end of the sunk Pel-Air Westwind jet

The ATSB has now recovered the black boxes from the Pel-Air crash site that it should have promptly retrieved in 2009.

It always knew where the Westwind jet was. All that was lacking was competency and courage in the so called leadership of the relevant agencies, and the intelligent engagement of the responsible Ministers in successive Labor and Coalition governments.

A big ask where Ministers don’t have the guts, wits or courage to question the positions taken by the administrative branch.

Updated: 12 November 2015

During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra. The part numbers and serial numbers of the recorders agree with the maintenance documentation for the aircraft. The recovery and storage of the recorders was witnessed by an officer of the Australian Federal Police. Examination of, and data recovery from, the recorders is expected to commence during the week of 16 November 2015.

This leaves the ATSB with the more difficult task of finding those flight recorders that might help solve the mystery of the disappearance of MH370, whether it found it and didn’t recognise it or not.

This might also require more than black boxes, through the recovery of smart phone and tablet chips from somewhere on the bottom of the Indian Ocean.

MTF..P2

[Gobbledock]

Waste of time unfortunately. The boxes will be rooted. Too many years in the salty waters. I hope I'm wrong, happy to be very very wrong, but I reckon the things will be unreadable.

[Kharon]

Choc Frog for Comet.

Comet - “Which is a pity, as this is an historic occasion. It is the first time anywhere in the world that flight recorders have sat in shallow water in a known location, but a government crash investigation department waited six years to recover them.

Even in distant dictatorships and untrustworthy regimes of history, such a go-slow has never been documented before

Beat me to it Comet –“[but] a government crash investigation department waited six years to recover them” is not quite accurate – it took a Senate Inquiry and an embarrassing TSBC peer review to persuade the Minister to force ATSB to effect the retrieval and write a honest report. 

Had it not been for those two events, make no mistake, the CVR would still be where it fetched up.  The truly abhorrent part is the ATSB had to be forced, dragged screaming, to effect recovery and to reopen the investigation.  One can only wonder why.

[ventus45]

We have a problem.

Now that the boxes have finally been recovered, much to the ATSB's displeasure, who will "supervise" the downloading and analysis ?

I would not "normally" suggest this, but GIVEN THE "HISTORY" AND "FLAVOURS" of this PANTOMIME OF AN INVESTIGATION over the last SIX years, the core troubling issue that we have here, is "whether or not we can trust" the ATSB.

Can we trust the ATSB to produce a full, honest and unbiased analysis from the boxes ?
Only a naive fool would be so trusting at this point in proceedings.

We all know the ATSB never "wanted" the boxes to ever see sunlight.
There are nagging questions as to "why".

Many months ago, (2nd February 2015) I speculated that a possible answer could be encapsulated in the phrase, "There is no evidence your honour".  
See here: http://www.pprune.org/8851000-post700.html

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Perhaps there is some potentially "unhelpful evidence", that as far as the ATSB, ASA and CASA are concerned, would very much be best left in the murky depths.

If there is any "unhelpful evidence", how can we be sure that it will ever see the light of day, even now ?

We may need to adopt the French system of dual investigations, both legal and technical.

Perhaps the Federal Police should be INVITED to "sit in on this one", purely in the interests of "investigative probity", of course.

Perhaps the miniscule should so "direct" ?

[Peetwo]

We have a problem.

Now that the boxes have finally been recovered, much to the ATSB's displeasue, who will "supervise" the downloading and analysis ?

I would not "normally" suggest this, but GIVEN THE "HISTORY" AND "FLAVOURS" of this PANTOMIME OF AN INVESTIGATION over the last SIX years, the core troubling issue that we have here, is "whether or not we can trust" the ATSB.

Can we trust the ATSB to produce a full, honest and unbiased analysis from the boxes ?
Only a naive fool would be so trusting at this point in proceedings.

We all know the ATSB never "wanted" the boxes to ever see sunlight.
There are nagging questions as to "why".

Many months ago, I speculated that a possible answer could be encapsulated in the phrase, "There is no evidence your honour".
Possibly because some potentially "unhelpful evidence" would best be left in the murky depths ?

If there is any "unhelpful evidence", how can we be sure that it will ever see the light of day, even now ?

We may need to adopt the French system of dual investigations, both legal and technical.

Perhaps the Federal Police should be INVITED to "sit in on this one", purely in the interests of "investigative probity", of course.

Perhaps the miniscule should so "direct" ?

All excellent points you make "V" but it is still a very large probability that the recorders will be dead; or the data corrupted; or totally unreadable...

No IMHO (and many others) there is a far bigger issue here and it lies in this part of the ATSB investigation update:

...During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra...

 
And from the Senate PelAir Inquiry:

Senator XENOPHON: There is a briefing note on points for consideration in relation to ATSB recovery of aircraft flight recorders for the Westwind aircraft, VH-NGA—and it goes through various things. It talks about an overview of flight crew, recovery options, issues, risks, decision points, the costs and the benefits. It talks about the ATSB's reputation of being seen as acting seriously when appropriate and fulfilling its share of the commitment associated with the considerable costs of installing and maintaining black boxes. It said 'present indications show a likelihood of strong safety measures in both normal and abnormal flight conditions based on existing data'. Then it talked about the benefits and costs, risks and ATSB's reputation for being relevant on risks. It says, 'Next year's budget was reduced because of this year's underspend. We cannot assess the accuracy of the pilot's perceptions.' Following the EMT, it advised the approved deployment of the investigation team in Norfolk Island to conduct a search for the aircraft using a ping locator. They also approved funding of up to $20,000 to recover the recorders and were open to discussions on further expenditure if required. So there clearly was a detailed discussion. The conclusion early on seemed to be to recover the cockpit voice recorder, but it was not recovered. We are all mystified—or I am. I think my colleagues are also mystified as to why we did not recover it.

Mr Dolan : At the initial stages, we understood the aircraft was in comparatively shallow water and that access to the recorders would be reasonably achievable by a diver or other mechanisms without too much difficulty. That brief was to convince me to make the necessary allocation of resources to retrieve the flight data recorder and the cockpit voice recorder. Upon investigation, it became clear that the depth at which the aircraft was in the water, its location at a remote island, Norfolk Island, and the work health and safety standards applying to diving to those depths meant that there would have been a substantial cost of recovery.

The requirement was effectively that there be a decompression chamber, none of which was available on Norfolk Island, for the full time of the retrieval because of the depth at which the divers would be operating. When we got a reasonable and first approximation assessment of that, in the knowledge that, from our point of view, the key information we had about flight decision making would not have been recorded on the cockpit voice recorder which only had a two-hour time on it—

Senator XENOPHON: That is that 08:00 weather detail thing?

Mr Dolan : The crash was nearly at 10:30 and there is only two hours on the cockpit voice recorder. So we did a benefit-cost analysis of recovery and formed the view that the costs substantially outweighed the benefits.

Senator XENOPHON: So let us not labour the point. That was an earlier assessment and subsequent assessment said that it was going to cost a lot more?

Mr Dolan : Correct.

CHAIR: Even though someone offered to do it for $500.

Senator EDWARDS: Is that right?

CHAIR: Yes.

Senator XENOPHON: But it would not have been on, on health and safety. Chair, to be fair to the ATSB, there is no way—

Mr Dolan : I would be unable to countenance that in terms of my responsibility.

CHAIR: As for your occupational health and safety background I am not allowed to climb up on my bloody bulk tanker, which I have been climbing on for 40 years, to put a hose in the top of it because it is not safe to climb up the side on a ladder on a fuel tank.

Mr Dolan : Falls from heights are a substantial cause of injury—

CHAIR: Yes, mate, but I have been doing it for 50 years and everyone else has been doing it. But there you go. All right and okay and we are grateful for your evidence.

 

And then this puerile, spin & bulldust gotcha moment

Which, if you will remember, Dolan later had to retract because Sen Fawcett actually had the correct version for the time of the accident.

Now apparently the tail of VH-NGA was roped & dragged towards the surface in early 2010 but then left to settle back on the ocean floor at 45m.

There is proof here that the tail was left roped to a buoy, note the date of the video upload was March 2010:

Dear Ag PM - Not only is the above evidence that your Chief Commissioner has lied to the Parliament but also he has hindered the carriage of a ATSB investigation for the better part of six years. This could (not should or shall) be interpreted as a breach of S24 of the TSI Act:

Offence to hinder etc. an investigation
(1) A person is guilty of an offence if:

(a) the person engages in conduct; and

(b) the person is reckless as to whether the conduct will adversely affect an investigation:

(i) that is being conducted at that time; or

(ii) that could be conducted at a later time into an immediately reportable matter; and

© the conduct has the result of adversely affecting such an investigation (whether or not the investigation had commenced at the time of the conduct); and

(d) the conduct is not authorised by the Chief Commissioner.

IMHO this should (not shall) be grounds for his instant dismissal...

Yours disgusted P2

[ventus45]

P2, I was editing my post when you did yours.  See the changes and the Pprune post referenced therein.
http://www.pprune.org/8851000-post700.html

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Regarding the Boxes:

As I understand the specs, there is no conceivable reason for the boxes to be "unreadable".

The "ditch" was well within box survival specs, and although 6 years "might" disolve the box in a "beaker" of nitric acid, 6 years in seawater WILL NOT.

If it turns out that the ATSB claim in a few days time that the boxes are unreadable, I would be willing to call foul, and send in the Federal Police with an SAS Escort.

The question in my mind still is: "what was the real reason" for not recovering the cvr.

Dolan made out that the Nandi transmission would not be on the tape.
I contend that is irrelevant, because the Nandi tape should still exist, and diplomatic pressure could be brought to bear to get it, IF there is the political will.  Cue Senators - Minister.  

What occured in VH-NGA during the two hours of the tape may give valuable clues to what the crew got from Nandi, what they heard, what confidence they had in it, how they interpreted it, how it fitted into their "decisions".

It is unlikely, given the situation that the flight crew were in, that they just sat there fat dumb and happy as the minutes, and miles dragged on, for two hours plus.  

There would have been discussion, and review of what information they had.  That would be telling, and that is what we must know.  Every word, every inflection of voice.  The lot.  It may result in the "fingers" being pointed in "other directions", not just the "crew".  We need to know if that is the case, and I firmly suspect, that is the real reason why the ATSB wanted to leave the box in it's watery vault.

In any case, in the interests of CRM in "a tight spot", the full audio of this CVR "should" be released. Perhaps Dom and Chloe would be happy to agree now ?

[Kharon]

Can we trust the ATSB to produce a full, honest and unbiased analysis from the boxes ?

Only a naive fool would be so trusting at this point in proceedings.  We all know the ATSB never "wanted" the boxes to ever see sunlight.  

There are nagging questions as to "why"

Good points “V” and well made – P2 has raised some additional serious matters which, IMO demand an AFP investigation into the whole squalid affair.  PAIN had suspicions that quite a bit of the ATSB – CASA joint venture was ‘skewed’ and that there were possible breaches of the TSI.  Certainly liberties were taken, the spirit and intent obliterated, whittled down to a fare-thee-well by callous, cynical word weasels There also were some strange, off beat’  ‘internal’ events which have not even been addressed, let alone satisfactorily explained.

I have – HERE – provided a link to a library file; which, if you care to download will provide an early draft version of a Sup, which, in part, frames some of the questions.

Whether or not those transgressions can be transmogrified into charges is not really the point (much as I would like to see it so).  The point is WHY?  I’d bet a pint of good ale that even the Senators are still puzzled as to motive.  It has me intrigued.  The wheels really started to come off during the Senate inquiry; which prompted the supplementary submission from PAIN to the Senate committee.

If you would like to see the whole submission (FWIW) – PM me and I’ll send you access links to the whole shooting match – be warned, there is a bit of reading.   History now; rhetoric and mouldering paper. But, we do have the pleasure of watching Dolan and Skidmore ‘doing their thing’, in public, at tax payer expense – as was the Senate Inquiry.  

Heigh Ho.

[Kharon]

Extract from the Norfolk play.

Hattley: “Is this a rope I see before me”  (in the background ring, ring, ring ring).

Hattley: “’Forsooth, tis the bearded one – will I risk his wrath and ignore him?”  “Nay, let me advise his snakeship that all is well and I can see the tail of beast”.  “Hello – Yes boss, WHAT? – drop it, but I can touch it, verily is the beast roped and drawn toward the shore”.

(Muffled squawking in the back ground – Click”

Hattley: – “DUCK IT – duck it all, put it back boys – yes, that’s right – orders from on high; put the little ducker back – lets go home”.  (Sounds of moaning, groaning and muttering of disbelief).

[Peetwo]

"..BBB your despicable..!!??"

 


"K" quote : 

Extract from the Norfolk play.


Hattley: “Is this a rope I see before me”  (in the background ring, ring, ring ring).

Hattley: “’Forsooth, tis the bearded one – will I risk his wrath and ignore him?”  “Nay, let me advise his snakeship that all is well and I can see the tail of beast”.  “Hello – Yes boss, WHAT? – drop it, but I can touch it, verily is the beast roped and drawn toward the shore”.

(Muffled squawking in the back ground – Click”

Hattley: – “DUCK IT – duck it all, put it back boys – yes, that’s right – orders from on high; put the little ducker back – lets go home”.  (Sounds of moaning, groaning and muttering of disbelief).

Love it "K" & TY   Brings to mind vivid images of Hattley & Co on that fateful day when the tail of VH-NGA was roped & starting to be lifted - why did they stop?

Now apparently the tail of VH-NGA was roped & dragged towards the surface in early 2010 but then left to settle back on the ocean floor at 45m.


There is proof here that the tail was left roped to a buoy, note the date of the video upload was March 2010:

And then three days ago :

...During the afternoon of 11 November 2015, the rear section of VH-NGA, which contained the flight recorders, was lifted onto the deck of PMG Pride. Both the cockpit voice recorder and flight data recorder were removed from the wreckage and placed into sealed containers in preparation for transportation to the ATSB’s technical facilities in Canberra...

&..from the Senate PelAir Inquiry Hansard 22/10/12:

Senator XENOPHON:  ..It talks about the ATSB's reputation of being seen as acting seriously when appropriate and fulfilling its share of the commitment associated with the considerable costs of installing and maintaining black boxes. It said 'present indications show a likelihood of strong safety measures in both normal and abnormal flight conditions based on existing data'. Then it talked about the benefits and costs, risks and ATSB's reputation for being relevant on risks. It says, 'Next year's budget was reduced because of this year's underspend. We cannot assess the accuracy of the pilot's perceptions.' Following the EMT, it advised the approved deployment of the investigation team in Norfolk Island to conduct a search for the aircraft using a ping locator. They also approved funding of up to $20,000 to recover the recorders and were open to discussions on further expenditure if required. So there clearly was a detailed discussion. The conclusion early on seemed to be to recover the cockpit voice recorder, but it was not recovered. We are all mystified—or I am. I think my colleagues are also mystified as to why we did not recover it.

Mr Dolan : At the initial stages, we understood the aircraft was in comparatively shallow water and that access to the recorders would be reasonably achievable by a diver or other mechanisms without too much difficulty. That brief was to convince me to make the necessary allocation of resources to retrieve the flight data recorder and the cockpit voice recorder. Upon investigation, it became clear that the depth at which the aircraft was in the water, its location at a remote island, Norfolk Island, and the work health and safety standards applying to diving to those depths meant that there would have been a substantial cost of recovery...

Okay from the Hansard record (& above) we can now establish some uncontroversial FACTS.

FACT - The decision to not retrieve VH-NGA's CVR/FDR in early 2010 was never about OHS issues?

FACT -  The decision to not retrieve VH-NGA's CVR/FDR in early 2010 was never about cost, the NX Hansard quote bears that out?

On this point it should also be remembered that:

(a) Although hearsay the "K" quote is as near as close to a factual account as we can establish from reliable (no vested interest) informants/witnesses. Therefore the cost of recovery had been allocated, paid for and the job 99% completed?

(b) It should also be remembered that CASA - although shortly after receiving extra funding of $89.9 million - declined a ATSB request to contribute to the cost of recovery of the blackboxes? 

FACT - Chief Commissioner Dolan has perpetuated - & continues to perpetuate - these lies for nearly 6 years?

He has lied to the victims of the Pel-Air VH-NGA Norfolk Island ditching;

He has lied under oath to the Parliament; and

He has lied to the travelling public - the question (as the "V" post highlights) is WHY???

Mr Dolan..

  


MTF..P2

[Peetwo]

ATSB/BASI history of water phobia??

The writing is on the wall, in the media, for all to see, both inside and outside the aviation community.

Re ATSB:
Clearly, yet another Beaker report, not worth reading, coming up (eventually).
They have their "template" from the "Pelair-Mk-1" saga.
Just change the names, dates, places - a little edit here - a little edit there.
Done and dusted.
Get it out fast too.
Got to get those "completed" stats up.

Re CASA:
Clearly, a carbon-copy re-run of DJ's charge sheet coming up, but this time, no doubt,  with a few more thrown in for, let's just say, "spice".
Look at it from the regulator's viewpoint.
This time, the guy can be charged, tried, and convicted, in absentia, and best of all, no likely appeals to that pesky AAAT.
Everything is in their favour.
They will want to savour this one, salivate even.

It makes one wonder.
What is the real definition of tyrany ?

Is what is happening clearly not a "perversion of due process", perhaps even an "outright contempt of due process" ?

To hell with the impotent miniscule.

Perhaps it is time for the Federal Court to intervene, promptly, and directlly. - Here, here ; long overdue I would have thought??

Comet's comment , COTY??- “…the main casualty will be our democracy”

Combined with the "V" post (above) and in light of the atrocities in Paris, I thought the following chain of excellent commentary on Ben's blog piece - ATSB now has only one set of black boxes lost at sea; or here on AP - ending with perhaps a nomination for 'comment of the year' by comet was worth regurgitating..   

  comet
Posted November 15, 2015 at 5:47 am | Permalink

The Pel-Air story is about government opaqueness.

We don’t know – and can only guess – why the governent safety investigator didn’t want to get to the truth, or why two government ministers (Albanese and Truss) took no interest in forcing the ATSB into line.

Unfortunately the atrocities in Paris will give governments around the world the cover they need to become more opaque and less open, while at the same time monitoring their citizens’ every move, and introducing harsher penalties for whistleblowers.

A bad event gives governments the excuse to start other bad events (eg Iraq wars). Aviation will suffer, but even worse, the main casualty will be our democracy.

'Vive la France!'-  P2


Late comment from another ditching survivor - Rod Lovell 

28

Rod Lovell
Posted November 20, 2015 at 8:04 am | Permalink

Nothing new. In my accident (VH-EDC) they RELUCTANTLY recovered the crucial starboard engine after two months underwater.

29
Rod Lovell
Posted November 20, 2015 at 8:11 am | Permalink

Just jumping on the bandwagon. From what I’ve experienced, the investigation into my accident by (the then) CAA and BASI was disgraceful.

I said about 20 years ago….

“Overall, I take great exception to the innuendo in the BASI report regarding my lack of
professionalism. Throughout my flying career I have always strived to maintain a highly
professional attitude and this flight was no exception. Some highly experienced and respected DC-3 pilots attest to my abilities in handling these and other aircraft.


 The report’s coverage of the circumstances of the ditching are inaccurate, superficial and in certain areas, untrue. It is obvious that the flight operations aspects of the report were conducted without consultation with experienced and impartial DC-3 specialists. The fact that BASI did not carry out flight tests on a DC-3 of similar airframe and engine hours is but one indication of the investigation’s lack of objectivity.”


I seriously doubt whether anything in “fort fumble” or “the sheltered workshop” will ever change.

Hmm...doesn't bode well for the MH370 SIO search does it?
"..BBB your despicable..!!??"

 

MTF...P2

[Peetwo]

Is it just me?

Yesterday the ATSB released their final 'Short Investigation Bulletin' for the year - Aviation Short Investigations Bulletin - Issue 45. At the top of the SIBs page it states:

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

This is Dolan speak (weasel words), for.. "we have limited resources to spend on full blown incident (versus accident) investigations, so if a desktop investigation can be conducted  which will conserve resources then that is what we will do."

However I am not sure if pushing that 'Short Investigation' definition to include a 'serious incident' where a near collision involving a 60 tonne Orion P3-C aircraft and a Schweizer 269C helicopter, over a built up area necessarily justifies a limited, short investigation budget - AO-2015-101.

On sighting the Orion, the pilot of JXO had immediately initiated a climb to avoid a collision, and estimated the Orion passed about 100 ft below. On hearing the controller pass the Orion as traffic to the pilot of JXO, the Orion crew immediately became concerned about the helicopter’s proximity, and looked for it. The co-pilot (non-flying pilot) of the Orion sighted JXO, assessed there was a risk of collision, and called ‘go low, go low, go low’. The captain (flying pilot), also sighted JXO, and increased the rate of descent to pass beneath the helicopter. The Orion crew estimated that JXO passed about 50 ft directly above the Orion, and were concerned it may collide with the Orion’s vertical tail fin. On the radar SDD, at 1514:25, both aircraft appear in the same position at 600 ft (Figure 6).

It is evident, from the safety actions section of the report, that the RAAF are taking this incident very seriously:

Safety action

Whether or not the ATSB identifies 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.

Department of Defence
As a result of this occurrence, the Department of Defence advised the ATSB that they are taking a number of safety actions. These include the following:

Compromised separation recovery training

The Department of Defence has released a Standing Instruction that mandates annual compromised separation recovery training for all air traffic controllers.

Controller briefing

All controllers will be briefed on the events and findings of the incident as an element of compromised separation recovery training.

Tower simulation capability

Tower simulation capability is being introduced to enhance compromised separation recovery training.

Additionally, simulation will be used to:

• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with processing complex traffic scenarios
  
• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with application of ATC priorities
  
• assess controller proficiency when live traffic levels are below that required to judge controllers’ abilities to process complex traffic scenarios
  
• provide controllers with regular exposure to compromised separation recovery scenarios, to improve decision making and ensure the associated actions become instinctive.
  
  

Airspace procedure briefings

The Edinburgh controllers will provide airspace procedure briefings to pilots who conduct airwork within and around Edinburgh airspace. The Airservices Australia Aeronautical Information Publication (AIP) En Route Supplement Australia (ERSA) entry for Edinburgh will be amended to include a section detailing the requirements for pilots of civil aircraft intending to conduct airwork within, or near, the Edinburgh control zone, to have airspace briefing.

 Hence (I guess) the ATSB quick wrap up of this investigation. However this incident had the potential for a lot more civilian fatalities than the sole occupant of the helo, if the Orion aircraft, minus tailfin, was unable to recover and spun out of control into outer Adelaide suburbia. 

Figure 2: Operating area of JXO, Edinburgh Control Zone and relative tracks


Source: Airservices Australia – annotated by the ATSB  

Maybe it is just me but a visual separation estimate of between 50-100 feet is just way too close for comfort - UFB!

P2 Comment: That said the ATSB Short Investigation team member(s) in collating and writing that report (in less than 4 months), did a sterling job with, 'by definition', very limited resources - Top job!


MTF..P2