[Gobbledock]

Tick Tock goes the orange clock

Not much has changed at Crapstar since the A320's were phased in. Do a data analysis of the past 10 years worth of ATsB reported incidents and you will shit yourself. It's only a matter of time until one of these incorrectly loaded and/or incorrectly trimmed aircraft don't make it off the ground. It was worse when they did 25 minute turnarounds. An almost impossible task to do safely with 170 pax on and off. Big Trev was always popping foofer valves at the lack of OTP (no wonder really), and the little Irish mincer was always monitoring his bonus payments!

Gotta love this bit;

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

Here it is below dissected for you Greg, as obviously you feel there are no safety risks with incorrectly loaded aircraft, much the same way that you feel aircraft that aircraft striking each other (light contact) also isn't a safety issue;

"The short turnaround time".

Yep, daily operational pressures all for the sake of earning the Executives massive salaries and bonuses. Safety last.

"combined with this being the last flight to Brisbane that night"

Mope operational pressure on crew and ramp staff. Safety last.

"the assumption there was a transcription error, resulted in the leading hand not requesting a new deadload weight statement and container card and loading the incorrect container on the aircraft..."

Incompetence? Laziness? Operational pressure? Culture? Or just safety last?

One day Professor Reasons cheesy holes are all going to line up....just sayin.

Tick Tock

[Kharon]

Playing the odds.

Trains are famous, the world over for ‘On Time Performance’ and people love it, old Mussolini made a political career out it. But consider the advantages a train system has; no conflicting traffic; weather not a big problem, dedicated line to destination and, barring accident or breakdown, apart from the human element, trains should run like clockwork.

The common or garden Omnibus service has other problems to contend with; traffic for starters, the weather, road conditions and people fumbling and stumbling on and off. At 0600 o’clock in any city your ‘bus’ will, like as not, be on time and may even meet it’s schedule and arrive on time. After about 0730 – all bets are off, mayhem rules.

Such is the reality of mass ‘public transport’. Delays and frustration are routine; but you never see a bus driver racing to meet a schedule, they drive carefully, make up what time they may in the prevailing conditions and have no worries about returning to the depot ‘late’. They have no curfew to concern them, no great advertisement PR pressure to meet OTP; the bus was late – so what: they did the best they could, with what they had, safely, calmly and without pressure from artificial demands to be ‘on time’.

An airline is, essentially public transport with ‘complications’. Many, if not most of those ‘complications’ are based against this mystical thing dubbed ‘safety’. There are many, many more things which can lead an aircraft to tragedy, than those faced by the 0610 bus to town. Legally, technically and operationally, despatching an aircraft is not a simple as sending a bus or train on it’s journey.  In short: it takes more ‘time’ to achieve a departure. The public would be staggered if they knew the amount of variables which must be managed, before they even board the aircraft. The complicated spells which must be cast before hand and the conjuring must be properly managed before the doors close.

So time becomes ‘precious’; for all the wrong reasons.  Management demand ‘OTP’ and reasons are demanded when this best estimate is not achieved. Deflecting the reason for ‘delay’ has been an art form practiced by aircrew since Pontius.  This is wrong; OTP is not a ‘screaming’ need; if it is to become one, then, schedules must become ‘realistic’. Turn around times extended to suit the anticipated, sensible ‘worst case’. The ‘cake eaters’ want the aircraft in the air as often as possible, as full as possible and on time, every time.  Much subtle and not so subtle pressure is brought to bear on those who must meet the expectations and demands of ‘management’. This produces a ‘rush’ culture.

Good skippers are immune to this urgent pressure; a quick look at the holding point or a listen to the ATC ground frequency will provide a clear picture of how long it will be before becoming airborne; so, with checks complete, there is time to relax, watch and wait for the ‘paper-work’ to turn up. Now the crew maybe relaxed enough; but behind the scenes there is turmoil; rush, rush rush, push, shove and clatter. This is ‘Murphy’s playground and he revels in it.        

This OTP pony-pooh, combined with curfew, mixed in with ATC delays, added to poor flying conditions, added to, stressed, fatigued ground and aircrew; slowly stirred into ATC fatigue issues is a recipe for disaster; a pointless, tragic, disaster which need not have occurred had the ‘pressure’ to keep a nonsensical schedule not been hyped up to an essential priority.

When you’ve time to spare, travel by air. Gut busting and rushing about have caused more accidents than being ten minutes behind ‘schedule’ ever did; and Murphy has always ruled supreme. Slow down, calm down and schedule realistically, before someone get hurt.

Aye well; if I’m late tonight the 2200 hrs bus will probably be running late, i.e. on time in real time, (traffic) so no worries. Toot - toot.

[Gobbledock]

And those regularly occurring ELAC faults on the Airbus during power up, resulting in a return to the gate and a Gindgerbeer fully powering down the aircraft then powering her up again to remove the fault doesn't help OTP especially if it is a first flight.

[P7_TOM]

Naughty GD – how dare you mention on going ‘technical’ faults; there is no trend there. Just because it happens ‘regular’ like is no cause for alarm. Anyways; the ATSB – ‘trend setters’ are on the job – Hoody assures us that ‘trends will be monitored'. Lovely word – "monitored".  Of course, some would say that it was just a way of waiting for something to happen; then screaming ‘Eureka’ or some such fanciful nonsense and claiming “we” monitored the trend, right up to the big bang.

“Big bang?” intones the coroner.

“Yes your honour” says Hood in velvet tones; "we were monitoring right up to the very end; on the case like”.

“Ah”; says his worship – “so when V123 ‘bumped’  (is that the correct technical expression?) and sheared a third off QFU 456 wing, the fuel spill ignited by a passing catering truck, which blew up the fuel tanker, which exploded setting flame to the three near by aircraft; one of which was being fuelled at the time, exploded and set fire to the terminal, which due to shoddy building techniques collapsed and killed hundreds, you were aware of these probabilities?”

“Oh, absolutely M’lud” lisps Hood; "we had data all the way up to the very last moment”. 'Now, delightfully,  we have fresh data to work on; and you can rest assured that we have full ministerial support to keep our data base fully loaded”. "We are so very delighted to be of service to the travelling public; I’ve made a new video”. (Gush) “So excited to be sponsored by the MKR producers, we have the minister, bless, to thank for that”.

“Then you have no concern” says his lordship, “that this cannot happen again”.

“Oh! Heavens no Sir” says Hood is his best videoed appearance voice; “No and no again; why our trend monitoring is immaculate: almost complete and world class”. “Why, with a second event, monitored event, we will be able to assist another of our star researchers to obtain a higher degree and: and, a higher pay-grade too".  “I can assure you, that with full ministerial support, the Beaker legacy lives on”. (Small bow, exeunt stage left; high five to those waiting to give evidence; lunch next, on the expense account. Who knows – maybe a pretty young reporter to dine on- with).

What a wonderful word is 'monitoring' thinks Hood as he strolls away, seeking a vacant Uber lift (cost consciousness is an ATSB watch word).

[Gobbledock]

Yes Tom, the word 'monitor' is a snazzy little gem. A little bit like me saying I 'accept' your comment Tom. It doesn't mean I agree with it, nor does it mean I will do anything with it, I just 'accept' it.

The police constantly 'monitor' our roads plus the Police commissioner 'accepts' there are a lot of dickheads on the road. The result? People still die, the annual Australian road death toll gets bigger each year or stays close to the previous years figures.

Anyway I raise my middle finger high into the night sky to Mr Hood as a token of what I think about his pony pooh massaging of words and his lack of 'acceptance' of the fact that these ground incidents are becoming very regular and are very serious. So FFS, grow a set and quit waving about the wet lettuce leaf an do something mate.

[Peetwo]

J* find yet another elephant in A320 cargo hold

Rehash :

Hoody: "Pick a trend any trend??" -  

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

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

Here we go again -

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



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

DARREN CHESTER:

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



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

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

Final Report
Final Report
Download Final Report
[ Download PDF: 474KB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 1.83MB]
 

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

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

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

Just saying -



MTF...P2

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

What are the chances of that?

P7:

“Oh! Heavens no Sir” says Hood is his best videoed appearance voice; “No and no again; why our trend monitoring is immaculate: almost complete and world class”. “Why, with a second event, monitored event, we will be able to assist another of our star researchers to obtain a higher degree and: and, a higher pay-grade too".  “I can assure you, that with full ministerial support, the Beaker legacy lives on”. (Small bow, exeunt stage left; high five to those waiting to give evidence; lunch next, on the expense account. Who knows – maybe a pretty young reporter to dine on- with).

What a wonderful word is 'monitoring' thinks Hood as he strolls away, seeking a vacant Uber lift (cost consciousness is an ATSB watch word).

Just noticed there is yet another 'loading event' for the Hoodlum to dutifully add to his 'monitoring' database :

Loading related event involving Airbus A320, VH-VGI, Melbourne Airport, Victoria, on 21 December 2016
 
Investigation number: AO-2016-177
Investigation status: Active
 

• Summary
  

The ATSB is investigating a loading related event involving Airbus A320, VH-VGI, at Melbourne Airport, Victoria, on 21 December 2016.

During unloading, ground crew were advised that the incorrect unit load device had been loaded on the aircraft due to an error at the freight organisation.

As part of the investigation, the ATSB will interview personnel from the freight organisation and gather additional information.

A report will be released within several months.
 
General details

Date: 21 Dec 2016
 
Investigation status: Active
 
Time: 9:00 ESuT
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Loading related
 
State: Victoria
 
Occurrence class: Operational
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Mar 2017 
 
Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A320-232
 
Aircraft registration: VH-VGI
 
Serial number: 4466
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Melbourne, Vic.
Destination: Sunshine Coast, Qld
 
 
 


Last update 23 December 2016

My question is? - Why are the bothering to waste resources to investigate, after all this is just a run of the mill 'loading event'. Come on Hoody just flick it to the 'loading occurrence' monitor 'in tray' and move on mate - nothing to see here...  
MTF...P2

[Gobbledock]

P2;

My question is? - Why are they bothering to waste resources to investigate, after all this is just a run of the mill 'loading event'.

Well P2, first we had 'Beyond Reason', the methodology promoted by that beard on/beard off buffoon Beaker. Now we have 'Light n Easy', the investigative approach driven by Hood. Think about it; if two Virgin aircraft colliding on the Tarmac is just a 'light touch' and not considered to be serious, then surely incorrectly loaded ULD's wouldn't even make it to the back page of a lollie wrapper?

Very sadly Hoody is producing hot air and wet lettuce slaps. From his farcical 'correct the record' page to his softly softly nonchalant and cavalier approach to SERIOUS incidents is a disgrace. Once again we have another pussy whipped ATsB Chief pulling $700k per year to deliver SFS in record long timeframes.

Tick Tock Muppets.

P7 - Choc frog post.

[Peetwo]

Hoody back from hols -

Via the ATSB yesterday:

Commercial aviation safest in 10 years

Commercial air travel in 2015 was safer than in any of the previous 10 years, according to Australian Transport Safety Bureau (ATSB) research, released today.


The ATSB’s report Aviation occurrence statistics 2006 to 2015 found that commercial air transport in 2015 had one fatality from nine accidents. General aviation had 12 fatalities from 130 accidents and recreational aviation had 18 fatalities from 76 accidents.

ATSB Chief Commissioner Greg Hood said 28 aircraft were involved in fatal accidents in 2015 and a further 28 in an accident resulting in serious injuries.

“The majority of fatalities in the 10‑year period occurred within general aviation, with around 20 per cent of fatal accidents resulting from a loss of control,” Mr Hood said.

Thousands of safety occurrences involving Australian-registered and foreign aircraft are reported to the ATSB every year by individuals and organisations in Australia’s aviation industry, and by the public.

Mr Hood said that for all accidents, the highest accident rates occurred with recreational aeroplanes, followed by aerial agriculture, private/business and sport aviation, and recreational gyrocopters.

Of concern was that in 2014 (the most recent year flying hours data was available for), the flying training accident rate per million hours flown was more than double that of any year in the previous eight.

“The increase in accident rates involving flying training is an emerging safety concern—we’ll continue to keep a close eye on this sector to get a better understanding of the safety issues involved,” Mr Hood said.

Also increasing was the number of remotely piloted aircraft accidents and incidents. “This has gone up from 14 occurrences in the eight years from 2006–2013 to 37 in 2014–2015.

“Given the significant growth in the use of remotely piloted aircraft, it is likely that the number of incidents and accidents will continue to increase in the short term.”

Mr Hood said growth in recreational (non‑VH) flying and improving awareness of reporting requirements led to more than a tenfold increase in the number of recreational safety incidents reported to the ATSB from 2006 to 2015.

The aim of the ATSB’s statistical report series is to provide feedback and information to pilots, operators, regulators, and other aviation industry participants on accidents and incidents that have occurred, how often they have occurred, and what can be learnt from them.

The statistics are used by the ATSB to inform its SafetyWatch priorities.

Read the ATSB research report AR-2016-122 - Aviation occurrence statistics 2006 to 2015.
 



Last update 11 January 2017

I wonder how much of the statistics are a factor of the steady decline in the GA sector total flying hours? Unfortunately the BITRE GA hours are yet to be updated ( ) - see HERE.

However the Avgas fuel sales continue to flatline - see HERE. Although knowing FF they will merely say that is countered by the increase in Avtur sales...

And round & round it goes, however I think it is safe to assume that the significance of the ATSB report is negligible. As we know statistics in the hands of politicians and bureaucrats can be very cleverly manipulated to spread the propaganda that they want the average punter to believe... 


MTF...P2

[Peetwo]

Hoody back from hols -

Via the ATSB yesterday:

Commercial aviation safest in 10 years

Commercial air travel in 2015 was safer than in any of the previous 10 years, according to Australian Transport Safety Bureau (ATSB) research, released today.



The statistics are used by the ATSB to inform its SafetyWatch priorities.

Read the ATSB research report AR-2016-122 - Aviation occurrence statistics 2006 to 2015.
 



Last update 11 January 2017

I wonder how much of the statistics are a factor of the steady decline in the GA sector total flying hours? Unfortunately the BITRE GA hours are yet to be updated ( ) - see HERE.

However the Avgas fuel sales continue to flatline - see HERE. Although knowing FF they will merely say that is countered by the increase in Avtur sales...

And round & round it goes, however I think it is safe to assume that the significance of the ATSB report is negligible. As we know statistics in the hands of politicians and bureaucrats can be very cleverly manipulated to spread the propaganda that they want the average punter to believe... 

Meanwhile in an aviation safety parallel universe - In a world outside of our insular and regressive aviation safety bureaucracy (who it seems are now all inflicted with AIOS), other ICAO signatory States continue to truly uphold the principles of Annex 13 & 19 and the concept of SMS and proactively address safety issues as they present.

Reference from OS accidents thread yesterday:

...Moving on to another international investigation FR, brought to my attention by Baldwin Aviation, into a B737-800 runway overrun in 2013 at Pardubice in the Czech Republic, via SKYbrary:

Description
On 25 August 2013, a Boeing 737-800 (OK-TVG) being operated by Travel Service on a passenger flight from Burgas, Bulgaria to Pardubice as TS2907 failed to stop before the end of the runway after landing off an approach in day VMC and continued onto firm grass for 156 metres beyond the end of the paved surface to the left of the extended runway centreline. None of the 194 occupants were injured and the aircraft was undamaged.




The aircraft as finally stopped showing its deviation to the left of the extended runway centreline to avoid the 09 approach lighting after leaving the end of the paved surface [Reproduced from the Official Report]

...The Investigation noted that various details of the flight crew response once the aircraft had come to a stop, for example not shutting down the right engine until reminded to do so by a ground technician and instructing the senior cabin crew to disarm the slide and open Door 1L prior to the delivery of steps, were contrary to the Operator's applicable SOPs.

The FCOM landing performance data applicable to the landing made was examined and it was found that at the prevailing ELW, a flap 30 landing with auto brake 2 pre-selected plus a 70 kg addition for the inoperative thrust reverser would have required 90 metres more runway than was available even if the touchdown had been made within the TDZ. It was noted that a flap 40 landing in the TDZ with either auto brake 3 or full manual braking would have required only 1,840 metres plus an adjustment for the inoperative thrust reverser. A landing in the 09 direction would have avoided a tailwind component.

In respect of the deceleration actually experienced, it was also noted that the final approach had been intentionally flown "one dot low" which would have had the effect of delaying the touchdown, especially in the presence of a significant (although allowable) tailwind component. It was also considered that "braking action might have been influenced by the uneven distribution of the water layer on the runway profile" but noted that runway friction had been tested and found to be above the standardised Minimum Friction Level throughout.

It was noted that another of the Operator's Boeing 737-800 aircraft had been involved in a landing overrun event at Katowice, Poland earlier in 2013 but although this was known to be under investigation by the Polish authorities, "the results of (this) investigation had not been discussed with the Czech AAII up to the date of issue of this present Report".

The Cause of the overrun was formally recorded as "non-compliance with SOP by the crew and an incorrectly selected landing configuration for an aircraft of the Boeing B737-800 type under the given conditions at Pardubice".

Five Safety Recommendations were made as a result of the Investigation as follows:

• that Travel Service should adopt internal guidelines for monitoring of flight data and compliance with SOPs by their B737-800 crews.
  
• that Travel Service should, given the repeated occurrence of similar incidents, review training curricula for flight crew and the methodology for calculation of the distance needed for landing on contaminated runways.
  
• that Travel Service should adopt measures for flight and cabin crew training which are aimed at mastering the abilities to be applied to emergency procedures and disembarkation in the case of an aircraft (landing) overrun.
  
• that the Military and Civil Operators of Pardubice Airport should, on a regular basis, review the system of collecting data about the condition of aerodrome movement areas.
  
• that the CAA and the Military Aviation Authority should jointly propose procedures for the measurement of braking action at the national level given the regulatory changes in this area made by ICAO.
  

The Final Report of the Investigation was issued on 17 March 2014.

Okay so another incident with elements of non-compliance and possible normalised deviance of SOPs in the causal chain. This would seem to be the theme that SMS company Baldwin Aviation are endeavouring to pick up on in yet another of their excellent safety awareness initiatives.   

From BCA magazine via Aviation Week/Baldwin Aviation ... :

Safety: Normalization Of Deviance
Dec 21, 2016 James Albright | Business & Commercial Aviation
This article appears in the January 2017 issue of Business & Commercial Aviation with the title “Normalization of Deviance.”

[/url]Most pilots have probably heard the story from Greek mythology about Icarus, the ancient aviator who flew too close to the sun and came crashing down into the sea. Since it was Daedalus, his father, who designed and constructed those wings of bird feathers tied with string and wax, it can be said that not only was he the original aeronautical engineer, but he included a maximum cruise altitude in his design specifications. Fly too high, he warned his son, and the wax used to fasten the feathers would melt. It can also be said that Icarus was the first pilot to deviate from design limitations.
                                                                       


La caída de Ícaro, óleo sobre lienzo (Museo del Prado, Madrid)


Deviations in aviation are to be expected; in fact, regulations make allowances for them. Since aircraft designers and regulatory authorities can’t think of every possible circumstance, 14 CFR 91.3 gives a pilot in command the authority to deviate from Federal Aviation Regulations to the extent required if an inflight emergency requires immediate action. What about other deviations? Pilots may find themselves having to alter or skip a standard operating procedure (SOP) for safety reasons. Sometimes they may make decisions that, at the time, seem prudent. But on reflection, many of these decisions may have just been laziness or an error in judgment. Aren’t we all human, after all?

Yes, we do make mistakes and much of our training is designed to prevent or mitigate those before they become harmful. As professionals, we train to minimize deviations and to recover from those that do occur. All that is as it should be. If those deviations become frequent, however, there is a tendency to start accepting them as the new norm, to lower our standards and blur the distinction between what is acceptable and what is not. And thus the normalization of deviance.

Challenger’s Final Flight

The phrase “normalization of deviance” was coined by sociology professor Diane Vaughn in her 1996 book, The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, where she examines the tragedy of the 1986 launch of space shuttle Challenger. The corruption of the decision-making process at NASA serves as a useful illustration on how very professional people can be seduced in to normalized deviance.

The space shuttle’s solid rocket boosters (SRBs) were built by Morton Thiokol, which was quite literally the cheapest bidder. Each booster was 149 ft. long and 12 ft. in diameter, manufactured in six sections, and delivered to NASA in sets of two that were joined at the factory. The three combined sections were joined in the field with the help of two rubberlike O-rings and an asbestos-filled putty. The 1/4–in. diameter O-rings surrounding the rocket’s entire diameter were designed to keep the hot propellant gases inside the rocket and directed downward toward the nozzles. The secondary O-ring was meant to be redundant, a safety measure.

But early on in the program there was evidence of some “blow-by” beyond the primary O-ring. Engineers determined an “acceptable” amount of erosion in the O-ring and for a while these norms held up. Starting in 1984 the amount of damage to the primary O-ring was increasing. Engineers were initially alarmed but later became convinced that the damage was slight enough and the time of exposure was short enough that the risk was acceptable.


Maiden launch of Challenger Credit: NASA


In 1985, some of the SRBs returned with unprecedented damage, the majority came back with damage, and in one case the secondary O-ring was also damaged. For one launch, there was complete burn through of a primary O-ring. In each case, the decision was to further increase the amount of damage deemed acceptable and press on. When it was no longer possible to say the two O-rings were redundant, NASA decided to waive the requirement.

What also happened in 1985 was a series of launch decisions in colder and colder temperatures. While the overall shuttle program was designed with a temperature range of 31F to 99F as launch criteria, the SRBs were never tested at the lower temperatures. In fact, Thiokol stated that O-ring temperatures must be at least 53F at launch, or they would become brittle and would allow “extreme blow-by” of the gases. There was also evidence that the O-rings could become cold soaked and their temperatures would take time to recover from prolonged cold. But top-level NASA managers were unaware of the SRB design limitations and the 53F threshold didn’t hold firm. For one launch the engineers said, “Condition is not desirable but is acceptable.”

Temperatures on the morning of Challenger’s final launch were well below 53F. SRB engineers recommended a delay but NASA managers applied pressure on Thiokol management. Nevertheless, the engineers refused to budge. So, they elected to make it a “management decision,” without the engineers, and agreed to the launch. It was 36F at the moment of launch.

The O-rings on one of the field joints failed almost immediately. About a minute after launch a continuous, well-defined plume from the joint cut into the struts holding the SRB to the main tank and the SRB swiveled free. The flame breached the main fuel tank, which erupted into a ball of flame seconds later. The shuttle cabin remained intact until impact with the ocean, killing all on board.


O-ring diagram

Much of the reporting after the event focused on the O-rings. After the accident report was published, the focus turned to NASA managers breaking rules under the pressure of an overly aggressive launch schedule. But as Vaughn points out, they weren’t breaking any rules at all. In fact, they were following the rules that allowed launch criteria and other rules to be waived. The amount of acceptable primary O-ring damage went incrementally from none, to a little, to complete burn through. Over the years the practice of reducing safety measures with waivers had become normalized.

By 1986, there had been 24 previous launches, each cementing the soundness of the decision-making process. With thousands of highly qualified experts collaborating on many of the decisions, it was easy to think, “We know what we are doing.”
But this was rocket science. How about an example closer to home?

The Final Flight of N121JM

Experts who have accumulated an enviable amount of experience and a strong sense of confidence are at risk of normalizing deviance unless they have sufficient oversight and a strong peer group. The crash of Gulfstream IV N121JM makes this case.

On May 31, 2014, the crew of the GIV started their engines without running the engine start checklist and neglected one of the steps that would have had them disengage the flight control gust lock. They then skipped the after starting engines checklist, which would have required the flight controls to be checked; had they done this, they would have realized the flight controls were locked. They also skipped the taxi and line up checklists, as well as the requirement to check the elevator’s freedom of movement at 60 kt. They were unable to set takeoff thrust, realized this, but continued the takeoff anyway. The rest, unfortunately, is history.


Gulfstream IV N121JM wreckage Credit: NTSB


As details gradually surfaced from the [url=http://awin.aviationweek.com/OrganizationProfiles.aspx?orgId=26686]NTSB accident investigation, we in the aviation world were stunned. How could two pilots have been so inept? But their airplane was outfitted with a quick access recorder and we learned that this type of behavior was the norm for them. For example, the recorder revealed that they had skipped the full flight control check on 98% of their previous 175 takeoffs.

These two pilots did not fly in a vacuum. They regularly underwent formal (and not inexpensive) simulator training and had even passed their Stage Two International Standard for Business Aircraft Operations (IS-BAO) safety management system (SMS) certification. So, they were able to fool their instructors and auditors, and that served to reinforce the behavior as normal.

Why would two, highly experienced pilots give into the normalization of deviance? They had achieved an enviable place in aviation, flying a prestigious aircraft that might represent the pinnacle of any pilot’s career. A psychologist would have a field day examining their ego-based complacency that had been reinforced by decades of successful operations without so much as a scratch to their expensive aircraft.

Unfortunately, there is compelling evidence that they were not alone in such reckless behavior. At the NTSB’s recommendation, the NBAA conducted a review of data produced by 144,000 flights involving 379 business aircraft from 2013 through 2015 to determine adherence to required flight control checks prior to takeoff. In nearly 16% of the takeoffs, the pilots did only a partial check. In 2% of the takeoffs, pilots failed to perform any check of the flight controls at all.

Preventing or Curing the Problem

There are multiple paths to normalizing deviance. As in the space shuttle case study, we can become so focused on our mission objectives that we can rationalize away safeguards and common sense itself. We can also become convinced in our own greatness — we defy gravity for a living, after all — and that breeds the conviction that rules and regulations are “for the other guy.” And finally, as we see repeatedly in aviation, we can become so experienced at our profession that complacency displaces competency. No matter the cause, these factors can combine to ensnare us into accepting deviance as our normal behavior.

As with many things in life, it would be best to avoid the trap altogether. But even if trapped, pilots can claw their way out with the right mindset and a few techniques.

Follow standard operating procedures (SOPs). We often find ourselves having to adjust, reorder or even skip some SOPs because they don’t exactly fit the situation at hand, they would take more time than a widely accepted shortcut, or we think we have a better method. There are several problems with this behavior, of course. Operating ad hoc, in the heat of the moment, we risk not carefully considering all possible factors. If we skip or reorder steps, we risk forgetting something important or failing to consider any sequential priorities.

If we adjust an SOP on our own, crew resource management (CRM) becomes more difficult as others will have to guess about our procedures and techniques. Further, once we’ve violated the first SOP, it becomes easier to violate the second, and the third. Before too long the culture of having SOPs will erode and when that happens, all SOPs become optional. And in a small flight department, there is a low likelihood of “being caught” or challenged.

Any pilot who is tempted to deviate from an SOP should first think about measures to formally change the SOP. There is a definite art to this. You need to carefully analyze the existing SOP, try to understand why the SOP is constructed as it is, and come up with an improved alternative solution. Then, gather support from peers, and advocate the change to those who have the power to change things. Flight department leaders should work with crews to ensure that each SOP is pertinent, easily understood, easily followed and consistent with other SOPs in the department and fleet. If adjustments are needed, select a well-respected team member to spearhead the effort, institute a test phase and obtain manufacturer comments, if possible.

Train to a standard. Your training is only as good as your instructor and if you are taught to cut corners and to ignore all that has been learned over the years, you can be trained to deviate. This most often occurs when someone you respect or someone in a position of authority assumes the role of instructor but has already given in to deviant behavior. It can also occur when a professional training vendor has misguided ideas of what should or should not be taught, or does not exercise proper oversight of its instructors. Seasoned simulator instructor pilots can give into the normalization of deviance, too, and their preferred methods are not necessarily the right methods.

Instructors and students alike should always be willing to return to the source documents. If an instructor’s technique violates a manufacturer’s procedure, the instructor is duty-bound to advocate the change with the people who built the airplane, not with those who are flying it.

Training administrators should realize that some courses are merely square fillers that satisfy regulatory requirements but do not teach meaningful information. Others can become repetitive because most vendors seldom change their courses from year to year.

In either case, these courses will become boring and may actually become counterproductive. Administrators should seek honest feedback about each course and attempt to find alternate vendors, even for the good courses. A robust in-house training program can supplement these efforts and also serve to combat stagnation and complacency.

Improve and broaden your peer group. Of course no professional pilot sets out to bend the rules on the margins or flagrantly disobey all SOPs. But some end up doing just that. Good pilots can be corrupted by poor peer groups. If everyone else has already normalized deviant behavior, it will seem an impossible task to hold true to SOPs without upsetting the status quo. Even a good peer group can become so comfortable that it, too, will begin to accept deviance as normal.

No matter the cause, all it takes is one pilot to bring the rest of the group back into the fold. If just one pilot adheres to all SOPs and best practices, the others will take notice. That alone may be enough to fix what is broken.

It may also be possible to demonstrate the efficacy of an SOP against a deviation and attempt to convince your peers to participate. Years ago, as the newest pilot in a Gulfstream IV flight department, I was alarmed that the pilots followed a Do-Verify method for the after-engine-start checklist and often missed critical steps. I convinced them to put their procedure against the required Challenge-Do-Verify method and time them. We discovered that not only was CDV more accurate than DV, it was faster.

It could very well be that a majority of pilots in your flight department have the same issues with some nonstandard procedures and a group meeting to discuss the issues can solve the problem. You should obtain leadership buy-in first. Leadership may be surprised about the issue; you might be surprised how open to change they can be.

But what if the lead deviant is the boss? Greek philosopher Socrates taught conflict resolution through the use of probing questions. If a senior member of the flight department insists on a non-standard procedure, ask for the reasons behind that “to better understand how to accomplish the procedure.” Having to verbalize the rationale may force a reexamination of the entire thought process.

When I first showed up in a Gulfstream V flight department, the pilots did not use any type of verification method prior to executing a change to FMS programing. I asked how this method would prevent an entry error that could misdirect the aircraft. After some thought, they agreed they had no such verification and were open to a new technique.

It is easy to fall into nonstandard behavior without an occasional look from someone outside the flight department. If the entire organization normalizes deviance at about the same rate, no one will notice because they are all involved. It may be beneficial to request an outside look at the workings within, such as a complete SMS audit that includes a flight observation.

However, keep in mind that some SMS auditors may make things easy in an effort to generate repeat business. If that happens, little is gained other than a piece of paper that says you filled a square. You need to emphasize to your auditors that you want an honest assessment because your overriding goal is to make a good flight department even better.

Make safety conspicuous. One of the profound lessons of the Challenger tragedy is that decision makers believed they were making the right, reasoned ones each step of the way. But in hindsight they would have to agree that many of those decisions were wrong.

Pilots in the “expert” class are in remarkably similar circumstances. They are quite often under extreme pressure to minimize costs while expanding mission capabilities. Flight department managers are often asked to spend less and less on maintenance, training and operating costs. At the same time, their crews are expected to fly farther distances with correspondingly longer duty days. Skipping maintenance checks, training events and checklist steps are at first approached carefully with considerable thought and consideration. Formal waivers may have been instituted in an effort to do it “just right.”

Before too long, however, the envelope of what was considered a deviation and what was just “normal operating practices” can start to merge. These decisions are rarely black and white and plainly labeled as “we are about to deviate from a procedure we once considered sacred.”

A common problem in all types of professional aviation activities can be called “target fixation,” that is we become so focused on accomplishing a mission we can lose sight of the need to do so safely. One way to keep a perspective of the organization’s overall goal (i.e., moving people from Point A to Point B safely) is to always have in mind a backup plan (arrange alternate transportation in the event of a maintenance or weather problem, for example). By routinely briefing alternate plans, having to enact them may not seem too extreme a measure.

A poorly kept secret in many aviation circles is that the “safety first” motto is often quoted, but rarely enforced. Managerial actions, such as frequent duty day waivers and calls to “hurry up” can undo any spoken assurances. If you are a chief pilot and this alarms you, try to make a conspicuous show of it the next time safety is indeed first.
I once elected to scrub a trip because an aircraft stabilizer system was questionable. The manufacturer did not prohibit the flight but didn’t recommend it, either. So we missed our first trip in several years because we decided the flight was too risky. I could have confined the matter to those directly involved but decided it was a good case study for everyone in the department to consider. They had to know that we really would cancel trips when the risks became too high. Safety is first.

Learn humility. When we assign the title of “expert” to a pilot, we recognize that person for a technical skill gained from training and experience. We also imply that the expert will be more objective than a non-expert and will be better armed against the normalization of deviance. Unfortunately, the opposite can be true.

An expert can believe his or her knowledge and experience gives license to deviate. With experience comes confidence — in some cases to the extreme. Over-confidence and arrogance can be cojoined.

The antonym for arrogance is humility. A humble pilot realizes that even the best aviators make mistakes and that one’s guard can never be lowered, even when the title of “expert” has been rightfully earned. The best way to keep humble is to research the all too many mishaps of very good pilots who have given in to the normalization of deviance.

They’re readily available. Go to http://www.ntsb.gov, and select the “Investigations” tab for full accident reports. Another great source is http://www.baaa-acro.com, the Bureau d’Archives des Accidents d’Avions.

Deviance is Not Normal

As with many technical pursuits, deviations from the norm are a fact of life in aviation. Our SOPs cannot cover every situation. We make mistakes. If those procedures are found lacking, it is up to us to change them. We must also design safeguards and redundancies to ensure we can effectively recover from any of those inevitable mistakes.

It is up to the Daedalus in each of us to ensure the equipment and procedures are well designed, and it is up to the Icarus in each of us to use the equipment as designed and adhere to those procedures. 

  
Excellent article BCA...


MTF...P2

[Peetwo]

RAC: A Reasoned World of Aviation Safety - (read, absorb, consider)



Outside of the insular vacuum of aviation safety bureaucracy ensconced in Can'tberra, the rest of the World embraces the challenge of improving aviation safety standards and safety risk mitigation. Continuing along the same theme as the previous post, the following is another excellent article by the editor of the FAA Safety Briefing Susan Parson:

Risky BusinessThe What, How, and Why of Risk Management

by Susan Parson, FAA Safety Briefing

A ship is always safe at the shore — but that is NOT what it is built for. —

Albert Einstein

Once upon a time, pretty much everyone involved in aviation took an “accidents happen” view of the world. From time to time in my pre-internet youth, I would pick up the newspaper or turn on the TV news to learn about a major airline accident. The photos were always grim. The details of each accident differed, but the result was the same. The investigation would reveal some human, mechanical, or meteorological flaw. Government and industry would come up with a way to address the issue, and off we’d go until the cycle repeated with the next accident.

The “find, fix, and fly” approach resulted in a number of safety enhancements over the years. There was better training (including crew resource management, or CRM) for flight crews, maintenance personnel, and air traffic controllers. There were upgrades to airplanes and avionics. There was research on weather phenomena such as wind shear.

There were new rules to ensure that everyone complied with the changes.

These improvements made major accidents less common, but everyone involved in aviation eventually realized that just waiting for the next accident to put a spotlight on some heretofore undiscovered flaw was not the best way to improve aviation safety.

The community — to include government as well as all segments of the industry — also came to understand that even the most faithful adherence to rules and regulations will not prevent the next accident. There is no question that following regulations is a vital part of aviation safety risk management. The rules provide an essential foundation for aviation safety. They are meant to direct the pilot’s path toward practices that contribute to safe operation and away from activities that undermine it.

The problem is that while regulations are necessary, they are not sufficient in and of themselves. They offer comprehensive and sometimes exquisitely detailed treatment of individual issues. Still, regulations simply cannot cover the nearly infinite number of possible combinations of situations that can undermine safety. In this respect, regulations alone are like bricks without mortar.

System Safety

Enter the discipline of risk management, and the concepts of system safety. The terms are admittedly abstract and they have a formal (and somewhat formidable) official definition. But, as the characters repeatedly assert in the slapstick Airplane! movies, “that’s not important right now.” To make the concept more concrete, think of system safety as the mortar needed to bind individual regulatory bricks together and build a sturdy barrier to accidents.

You know about the regulatory “bricks,” so let’s focus on the “mortar.”

A system can be defined as a combination of people, procedures, equipment, facilities, software, tools, and materials that operate in a specific environment to perform a specific task or achieve a specific purpose. GA flight operations clearly constitute a complex system with many variables:

• Pilots have different levels of knowledge, skill, experience, ability, and discipline.
  
• Procedures, such as instrument approaches, can be very complex.
  
• Equipment, airframes and avionics, is changing rapidly.
  
• Services, such as those provided by airports and air traffic control, vary widely and are already changing as NextGen technologies are deployed in the National Airspace System.
  
• The flight environment, including weather, is a critical factor in the safety of every flight.
  
• External factors can have a substantial impact, especially if the pilot doesn’t consciously recognize them.
  

Risk Management

A key part of the system-safety approach is risk management, a decision-making process designed to methodically identify hazards, assess the degree of risk, and determine the best course of action. To put risk management to work in your personal aviation safety system, you need to be familiar with some of the basic concepts:

• A hazard is a present condition, event, object, or circumstance that could lead or contribute to an unplanned or undesired event. For example, a ¼-inch nick in the propeller is a hazard.
  
• Risk is the future impact of a hazard that is not controlled or eliminated.
  

A risk-assessment matrix shows that the level of risk posed by a given hazard is measured in terms of severity (extent of possible loss), and probability (likelihood that a hazard will cause a loss). Exposure (number of people or resources affected) can also be considered in assessing risk.

Here’s a practical illustration of both the “rule gap” and the hazard/risk relationship.
A few years ago, I sent a primary student out to do the preflight inspection. As required by school rules, he carefully checked the Cessna 152’s maintenance and airworthiness records before heading out to the airplane. All paperwork was in apple-pie order.

Reaching the plane, my student discovered a sheen of oil on the nosewheel fairing. When he bent down for a closer look, he noticed that it was fresh, and steadily increasing with the steady drip-drip-dripping of oil droplets escaping from somewhere in the engine compartment.

While he had established compliance with the paperwork and maintenance and airworthiness service requirements, my student correctly concluded that a bleeding airplane was not in a condition for safe flight. In terms of hazards and risks, the Cessna 152 oil leak was a hazard, but it would become a risk only if the airplane had been flown. So we went back inside for coffee, and wound up using the scheduled lesson time to discuss safety rules, safety realities, and the concept of safety risk management.

Practical (Easy) Risk Management

To make system safety and risk management practical for real-world GA operations, the FAA Safety Team (FAASTeam) promotes a simple three-step process:

1. Perceive, or identify, the possible hazards associated with each category in the well-known PAVE checklist:

• Pilot — e.g., experience, recency, currency, physical and emotional condition
  
• Aircraft — e.g., fuel reserves, experience in type, aircraft performance, aircraft equipment
  
• enVironment — e.g., airport conditions, weather (VFR and IFR requirements), runways, lighting, terrain
  
• External factors — e.g., impact of delays and diversions
  

The four elements of the PAVE risk assessment checklist.

2. Process, or analyze, by evaluating the severity, probability, and/or exposure of the risk posed by the hazard(s) you identified in step one.
3. Perform by finding ways to eliminate or mitigate the severity, probability, and/or exposure of each of the identified hazards.

With consistent use, cycling continuously through the three-P cycle can become a habit that is as smooth and automatic as a well-honed cross-check, interpret, and control scan taught in instrument flying.

Risk Management in the Airman Certification Standards (ACS) The FAA Risk Management Handbook (FAA-H-8083-2) observes that:

Learning how to identify problems, analyze the information, and make informed and timely decisions is not as straightforward as the training involved in learning specific maneuvers. Learning how to judge a situation and “how to think” in the endless variety of situations encountered while flying out in the “real world” is more difficult. There is no one right answer in Aeronautical Decision Making (ADM); rather each pilot is expected to analyze each situation in light of experience level, personal minimums, and current physical and mental readiness level, and make his or her own decision.

That’s why the new FAA Airman Certification Standards (ACS), which began replacing the Practical Test Standards (PTS) in June 2016, explicitly incorporate risk management into the certification standards for an airman certificate or rating.

While the PTS has long required the evaluation of knowledge and risk management elements in both the ground and flight portions of the practical test, it offers little more than a statement of the requirement and, in the case of “Special Emphasis” items, a list of subjects the Designated Pilot Examiners (DPEs) must evaluate. The ACS provides better guidance to applicants, instructors, and evaluators because it provides specific risk management and ADM procedures and behaviors associated with each Task, and it incorporates Special Emphasis items in the risk management section of the appropriate Area of Operation/Task. This presentation helps instructors make stick and rudder skills more meaningful by teaching them in the context of what the applicant must know and consider while demonstrating flight skills. On the practical test, it allows the evaluator to see and assess an applicant’s judgment and decision making in the context of actual flight operations. The ACS thus discourages the use of abstract and potentially subjective methods of testing these important skills.

Consistent with the 3-P risk management model, the ACS is also intended to communicate and demonstrate that risk management is a continuous process that includes identification, assessment, and mitigation of task-specific hazards that create risk. The risk management element identifies the circumstantial issues that aviators must consider in association with a particular task.

Because the level of risk that is acceptable to one pilot may not be the same for another, some have expressed concern that testing of risk management elements in the ACS will be too subjective. It is true that risk management is unique to each and every individual, but the ACS defines the circumstances, conditions, or risks applicable to each Task, not to the specific individual. Applicants will thus be tested on their awareness and mitigation of the risks associated with the Task at hand, which includes the applicant’s consideration of these elements in the context of the maneuver but taking account of the pilot’s experience and ability, the aircraft used, and the operating environment.


Photo by Susan Parson

Why Bother with Risk Management?

Aviators love to argue, and social media is full of lively debate about the “real” cause of GA accidents. Some threads focus on deficiencies in so-called stick-and-rudder skills, and suggest — incorrectly — that the addition of risk management diverts attention from airplane handling skills.

In fact, most accidents have multiple causes. Some of the most persistent factors in fatal GA accidents are maneuvering flight, continued VFR into IMC, and loss of control on takeoff. All imply some degree of deficiency in the pilot’s knowledge, skill, and risk management abilities. Even the world’s best stick-and-rudder pilot is at risk for loss of control if he or she has an inadvertent flight into IMC because of deficiencies in weather knowledge or risk management ability. Safety is not served by emphasizing just one of these three abilities; on the contrary, each supports the others. To paraphrase the familiar “all available information” regulation (14 CFR section 91.103), we need to use “all available means,” including risk management, to fly safely.

Learn More

• FAA Risk Management Handbook (FAA-H-8083-2)
  
• Airman Certification Standards
  

Susan Parson (susan.parson@faa.gov, or @avi8rix for Twitter fans) is editor of FAA Safety Briefing. She is an active general aviation pilot and flight instructor.

 
MTF...P2

[Peetwo]

One for the search 4 IP archive -

Possible candidate for the Hoody Hall of Shame & Shambolic ATSB pointless investigation archives? Couple of days ago I noticed this ATSB (apparently...WTF )  newsworthy investigation in their 'News items' webpage:

Take-offs without runway lighting highlights the hazards with change blindness

These incidents demonstrate the impact workload stress can have on operations.


On 19 August 2016, a JetGo Australia Embraer EMB-135LR, registered VH-JTG, operated scheduled passenger flight JG65 from Tamworth, New South Wales, to Brisbane, Queensland. At 2104 Eastern Standard Time, the aircraft began to taxi from parking bay 1 to runway 30 right (30R) with the taxiway and runway lights not activated. The captain taxied the aircraft onto the runway and immediately began the take-off run. During the take-off run, at a speed of about 70 knots, the first officer detected the runway lights were not illuminated and activated them using the pilot activated lighting.

On 28 August 2016, the same aircraft operated scheduled passenger flight JG65 from Tamworth to Brisbane. At 1937, the aircraft began to taxi from parking bay 1 to runway 30R. As the aircraft taxied, the runway and taxiway lights extinguished. The flight crew continued to taxi and lined up on runway 30R. The aircraft began the take-off run and departed runway 30R with the runway lights not activated.

No persons were injured and the aircraft was not damaged in the incidents.

These incidents demonstrate the impact workload stress can have on operations.
These incidents demonstrate the impact workload stress can have on operations. The short taxi created a high workload situation which impacted on the flight crews’ ability to detect the extinguished runway lighting.

The incident on the 28 August also highlights the hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this incident the flight crew did not detect the runway lights extinguish during taxi prior to departure.

Read the full investigation report AO-2016-108
 



Last update 19 January 2017

 
So for 'shits & giggles' I went to the SIB investigation webpage and read this report?? :

What happened

On 19 August 2016, a JetGo Australia Embraer EMB-135LR, registered VH-JTG (JTG), operated scheduled passenger flight JG65 from Tamworth, New South Wales (NSW), to Brisbane, Queensland (Qld). At 2104 Eastern Standard Time (EST), the aircraft began to taxi from parking bay 1 to runway 30 right (30R) with the taxiway and runway lights not activated (Figure 1). At 2107, the captain taxied the aircraft onto the runway and immediately began the take-off run. During the take-off run, at a speed of about 70 knots, the first officer detected the runway lights were not illuminated and activated them using the pilot activated lighting (PAL) (Figure 2). The flight crew continued the take-off.

Figure 1: Taxi path overview (both incidents)


Source: Airservices Australia, modified by ATSB

Figure 2: Take-off run of JTG on 19 August showing runway lights not activated (left) and then activated (right)


Source: Airport Operator

On 28 August 2016, the same aircraft operated scheduled passenger flight JG65 from Tamworth to Brisbane. At 1937, the aircraft began to taxi from parking bay 1 to runway 30R. As the aircraft taxied, the runway and taxiway lights extinguished (Figure 3). The flight crew continued to taxi, lined up on runway 30R and selected the aircraft landing lights on. At 1940, 48 seconds after lining up, the aircraft began the take-off run and departed runway 30R with the runway lights not activated.

No persons were injured and the aircraft was not damaged in the incidents.
Figure 3: JTG taxiing on 28 August with runway lights illuminated (left) and then extinguished (right)


Source: Airport Operator

Runway and taxiway lighting

The taxiway and runway lighting at Tamworth Airport was controlled by a PAL system combined with an aerodrome frequency response unit (AFRU), known as AFRU + PAL. To activate the lights, pilots were required to transmit a sequence of three transmissions on the common traffic advisory frequency (CTAF). Each transmission was to have a maximum duration of 1 second with the break between transmissions being a maximum of 1 second. On receipt of the appropriate transmission sequence, the airport lights were activated and the AFRU broadcast the automatic message: ‘Tamworth Airport CTAF, runway lighting on’ on the Tamworth CTAF.

Once the AFRU + PAL system was activated, the airport lighting remained on for 30 minutes. If it was reactivated during this period, the lighting would remain on for 30 minutes from the time of reactivation. 10 minutes prior to the end of the 30-minute activation period, the primary wind indicator (windsock) lights commence flashing to warn users that the airport lighting is about to extinguish (Figure 4). In addition, an automated message ‘Tamworth Airport CTAF, lights 10 minutes remaining’ was broadcast on the CTAF to advise 10 minutes of runway lighting remaining.

Figure 4: Flashing primary wind indicator showing the windsock illuminated when the runway lights were active (left) and not illuminated (right)


Source: Airport Operator

On 19 August, at 2039, the AFRU broadcast ‘Tamworth Airport CTAF, lights 10 minutes remaining’, the lights then extinguished at 2049. At 2107, during the take-off run of JTG, the first officer broadcast an AFRU + PAL activation sequence on the Tamworth CTAF and the runway lights illuminated.

On 28 August, at 1928, the AFRU broadcast ‘Tamworth Airport CTAF, lights 10 minutes remaining’, the lights then extinguished at 1938. At 2007, an AFRU + PAL activation sequence was broadcast by another aircraft and the runway lights illuminated.
There was no indication that the AFRU + PAL system was malfunctioning on the nights of the incidents.

Captain comments

The same pilot was operating as captain of JTG during both incidents. The captain provided the following comments:

• The captain did not notice that the runway lights were extinguished during either incident and were not aware until notified after each incident.
  
• The taxiway lights at Tamworth are of the recessed centreline type. The taxi from bay 1 to runway 30R is over a rise. Therefore, only three to four taxiway lights are normally visible from the point at which you turn onto the taxiway. The captain remarked that the raised type taxiway side lights found at other airports are more easily visible.
  
• Wind information for pre-flight planning is obtained through the flight crew electronic flight bag or automatic weather information service (AWIS). Therefore, they will only observe the windsock as a back-up, if it is available and close.
  
• During turn-around between flights, the flight crew do not wear headsets and will not hear the 10 minutes remaining broadcast if it occurs during this time.
  
• The responsibility for ensuring the airport lighting would be active was not assigned to either flight crewmember. There was no procedure for ensuring the airport lighting would be illuminated for the departure.
  
• Both incidents occurred at the end of long duty days, so fatigue may have been a factor.
  

First officer comments – 19 August

The first officer of the 19 August incident provided the following comments:

• The tiller in the Embraer 135 is located on the captain’s side. Therefore the first officer always acts as pilot monitoring[1] (PM) during taxi. The taxi from bay 1 to runway 30R is short and a period of intense workload. During this time, the first officer did not look outside the cockpit.
  
• The first officer did not look outside of the cockpit until the aircraft began moving during the take-off run. Once they looked outside, they immediately felt that something was not right. About five seconds later, the first officer detected that the runway lights were not illuminated.
  
• The first officer was PM for this flight. As PM, they were able to quickly activate the PAL and resolve the issue, and did not consider aborting the take-off.
  
• The first officer used the take-off data card for wind information and did not look at the windsock prior to departure.
  

First officer comments – 28 August

The first officer of the 28 August incident provided the following comments:

• The first officer did not notice that the runway lights were extinguished and was not aware until notified after the incident.
  
• The primary wind indicator at Tamworth is situated so that it is illuminated by light from the adjacent apron lighting and a red obstacle light is located above the windsock. On subsequent flights to Tamworth, the first officer has observed that this gives the appearance of the windsock being illuminated when the runway lighting is extinguished (Figure 4).
  

Aircraft lighting

The Embraer 135 is fitted with three landing lights and two taxi lights. The combination of these lights provides a substantial amount of illumination in front of the aircraft.

The taxi lights are used from the beginning of taxi until after departure. Prior to commencing the take-off run, the landing lights are also selected on. The landing lights provide considerably more illumination than the taxi lights.

All flight crew described the aircraft lighting as extremely effective at illuminating the runway ahead of the aircraft and reported no controllability issues during the take-off runs.

Parking apron lighting

Prior to both incidents, the aircraft parked at bay 1 for the embarkation of passengers (Figure 5). This bay is substantially lit by apron floodlights. These lights are not part of the PAL system and remain illuminated when the PAL system extinguishes the runway and taxiway lights.

All three flight crew commented that the apron lighting degraded night-vision and the short taxi from bay 1 to runway 30R did not allow time for eyes to adjust to the dark surrounds of the runway.

Figure 5: JTG parked at bay 1

Source: Airport Operator

Environmental conditions

Last light[2] on 19 August 2016 occurred at 1757, three hours and ten minutes before the take-off. At 2017, the moon was 19 degrees above the horizon and about 99 per cent visible. There was a clear sky.

Last light on 28 August 2016 occurred at 1802, one hour and 38 minutes before the take-off. The moon was below the horizon and the sky was clear.

ATSB comment

Two different PAL systems exist at Australian airports, PAL and AFRU + PAL. The activation sequence for each system is different.

CTAF recordings for the period surrounding each incident showed multiple unsuccessful attempts by other aircraft to activate the AFRU + PAL using the sequence of transmissions for a PAL system.

AIP ERSA INTRO paragraphs 23.4 and 23.5 detail the differences between the two systems and the correct transmission sequence to activate each system.
While this did not contribute to the incidents, pilots are reminded to be familiar with the identification and use of the different systems.

Safety Analysis

The illumination provided by the aircraft taxi and landing lights made it difficult to detect that the PAL was not activated. Due to the rise on the taxiway, the crew would only have been able to see a few lights ahead of the aircraft, and these would have been illuminated by the aircraft lights. Adding to this, both crew did not have an expectation that the lights may have been extinguished as the cues available did not assist. The auditory 10-minute PAL extinguishing warning could not be heard without headphones, and the windsock flashing light warning was not noticed as the crew obtained wind information using the flight crew electronic flight bag or AWIS.

As the company standard operating procedures did not assign a task of ensuring the runway lights were selected on to a specific role prior to taxi, there was also no procedural prompt to the crew.

The short taxi with a high workload further reduced the chance of detection.

Findings

• The crew did not activate the airport lighting and did not detect that the lighting was off prior to the take-off run.
  
• Available lighting from the aircraft taxi and landing lights, a lack of crew expectation, a short taxi with high workload, and no assigned role or procedure to check for runway lighting resulted in the crew not detecting the lack of runway lights.
  

 
I initially thought WTF are they thinking investigating such a 'something nothing' incident, that I would hazard a guess most reasonably experienced pilots have had happened to them from time to time. But then I also thought, well at least the potential safety issue was responsibly acknowledged & addressed by the operator (& apparently without any punitive murmurings from the regulator), so all's well that ends well...

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 these occurrences.

Aircraft operator

As a result of these incidents, the aircraft operator has advised the ATSB that they are taking the following safety actions:

Changes to procedures

• When activating the aircraft taxi lights the pilots must ensure that they confirm the status of the PAL.
  
• When conducting night operations at an unmanned airport, the pilots must activate the PAL or AFRU + PAL by keying the microphone on the appropriate frequency unless the aircraft immediately ahead has already done so. For example, if the aircraft 10 minutes ahead has turned the lights on it will not be necessary to activate the lights again as the lights will normally remain on for a period of 30 to 60 minutes depending upon the installation.
  
• If no traffic is evident then the pilots must activate the PAL prior to taxi for departure and within 15 nm of the aerodrome and whilst above the lowest safe altitude for arrival.
  

Then I read the 'Safety Message' and again I was left thinking WTF drugs were the ATSB on trying to make mountains out of molehills and paint associations with the excellent Transport Canada publication 'Deadly Omissions':

Safety message

These incidents demonstrate the impact workload stress can have on operations. The short taxi created a high workload situation which impacted on the flight crews’ ability to detect the extinguished runway lighting.

The incident on the 28 August also highlights the hazards associated with change blindness, inattention blindness and expectation bias.

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this incident the flight crew did not detect the runway lights extinguish during taxi prior to departure.

The Transport Canada article Deadly Omissions includes further information on change blindness, inattention blindness and expectation bias.

  
Maybe it's just me but I just find that so disingenuous and a WOFTAM of an investigation...
Then I saw one of the latest reported incidents that the ATSB has decided to investigate:

Aviation safety investigations & reports
Investigation title
Pre-flight preparation event involving Airbus A320, VH-VNC, Cairns Airport, Qld, on 21 January 2017
 
Investigation number: AO-2017-008
Investigation status: Active
 

• Summary
  

The ATSB is investigating a pre-flight preparation event involving Tiger Airways Airbus A320, VH-VNC, at Cairns Airport, Queensland, on 21 January 2017.

The flight crew lined the aircraft up for take-off from an incorrect taxiway intersection on the runway. Air traffic control alerted the flight crew who then backtracked the aircraft to the correct intersection prior to commencing take-off.  

As part of the investigation, the ATSB will interview the flight crew, review air traffic control communications and gather additional information.
A report will be released within several months.
 
General details
Date: 21 Jan 2017
 
Investigation status: Active
 
Time: 15:16 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Cairns Airport
 
Occurrence type: Navigation - Other
 
State: Queensland
 
Occurrence class: Operational
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Jan 2017 

Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A320-232
 
Aircraft registration: VH-VNC
 
Serial number: 3275
 
Operator: Tiger Airways Aust.
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Cairns, Qld

Destination: Brisbane, Qld
 
 
 


Last update 24 January 2017

  
Now being a former ATCO Hoody would well know that again this incident is a "something nothing" but yet his mob have decided to expend time, money and limited resources on investigating - WTD?? 

MTF...P2

Ps Q/ I wonder if the two investigations above reflect the fact that neither operator is not affiliated with QF, Jetstar or mainstream Virgin? - just saying...

[Gobbledock]

Whoopy doo, wrong taxiway - corrected.
Runway lights not activated - big deal. El Capitano could have done the takeoff with a blindfold on.

And besides, under the 'beyond Reason' methodology the ATsB adopted it has now morphed into the 'beyond giving a shit' methodology with aircraft potentially landing on barges, dangerous airspace issues around Melbourne, aircraft wings contacting each other 'lightly' (and on the odd occasion with aircraft tails), ditched aircraft parked in the waters of Norfolk Island providing an aquatic paradise for the reef fish, and many many other non-issues as defined by the ATsBollocks.....

Tick Tock Australia.

[Kharon]

Just saying.

Couple of points on the TW runway lights incident which ATSB could/should have considered before parlaying this into the Canadian ‘exemplar’ points scoring. First off, and its purely personal – I hate those apron lights; water/ condensation on the windscreen, dark night landing; or, early AM start up the shadows created in the cockpit require full internal lighting and the bight areas, particularly in rain or fog are like having the opposite direction cars using high beam – makes it really hard to see clearly – and anyway they completely bugger up your night vision.  Late night/early AM turnarounds, these lights are a particular problem, fatigue is creeping in and having spent some hours in a dark environment the ramp lights are an assault on the senses. Quick turn round and off into the darkness again; night vision severely reduced. As said – a personal gripe; nothing to be done about it – just saying. I should also mention that PAL does not reset during its active period; one must wait until the end of the period to gain additional lights on time; bright ramp lights, fast turn around, short taxi, high workload, NV shot, fatigued, bright taxi and landing lights, centre line nailed down – hell, could have happened to anybody. But no matter, the company have ‘corrected’ the oversight, but it has me puzzled – must the crew now wait for the light array to flash before keying them back on, to ensure another 30 minutes? Problem solved – I wonder.

Cairns is a whole different ball of wax. ATC need a thank you for spotting the error, a big one. Intersection departures need written ‘approval’ and dedicated RTOW data. There’s lots of vertical dirt, rocks and trees and stuff at Cairns, even with all the donkeys working hard, with the wrong data, all the OCH clearances are compromised , going OEI off compromised take off data is potentially lethal and there is not too much margin for error when high ambient temperatures are associated with 'heavy' aircraft. It is possible to lob onto the wrong intersection; rare, but doable. Interesting to see what ATSB will come up with as ‘causal’, whatever it is someone was very lucky ATC spotted it before the aircraft rolled, very lucky indeed (legally and operationally). Bravo ATCO.

[Peetwo]

Update: Hoody's bureau for top-cover investigations.  

Just saying.

...Cairns is a whole different ball of wax. ATC need a thank you for spotting the error, a big one. Intersection departures need written ‘approval’ and dedicated RTOW data. There’s lots of vertical dirt, rocks and trees and stuff at Cairns, even with all the donkeys working hard, with the wrong data, all  the OCH clearances are compromised , going OEI off compromised take off data is potentially lethal and there is not too much margin for error when high ambient temperatures are associated with 'heavy' aircraft. It is possible to lob onto the wrong intersection; rare, but doable. Interesting to see what ATSB will come up with as ‘causal’, whatever it is someone was very lucky ATC spotted it before the aircraft rolled, very lucky indeed (legally and operationally). Bravo ATCO.

1. Planetalking has now picked up on the above ATSB Desktop (Short Investigation)... :

Air Traffic vigilance prevents Tigerair stuff up at Cairns

One way to keep FNQ lovely and tidy is for airlines to ensure their flights have ALL of Cairns' runway available for take-off

Ben Sandilands


Another beautiful day at Cairns Airport and its ‘adequate’ runway

But for the timely intervention of an AirServices Australia officer in the tower at Cairns airport on January 21, a Tigerair Australia A320 bound for Brisbane would have attempted to take off from the wrong starting point on its 2580 metres long runway.

The flight would, according to pilots, most likely have taken off using only 2100 metres of the runway, provided nothing went wrong, such as an engine failure, or perhaps the mistaken use of less powerful but more economical thrust settings, it which case things could have gone badly wrong for everyone in the 180 seat jet.

Those are the thoughts of airline professionals who hold positions demanding complete attention to the requirements of safe airline operations, and who are aware of the pressure for quick turnarounds or punctuality.

The notification of the incident as worthy of investigation by the ATSB can be read here on its website, or a better illustrated report, and a short discussion of the incident, can be found on the Aviation Herald website, which is an invaluable free resource for those interested in no nonsense air safety reporting and which asks for a donation toward its running costs.

The ATSB expects to report its findings by May, a very short turnaround for a vital agency that is also under resourced.

2. Hoody on the case of the lost drone -

Loss of control involving remotely piloted aircraft Pulse Aerospace Vapor 55
Incorrect reference data can have potentially serious consequences in remotely piloted and manned aircraft.



On 27 September 2016, a Pulse Aerospace Vapor 55 remotely piloted aircraft (RPA), was operating a test flight at Lighthouse Beach, Ballina, New South Wales.

The RPA tracked according to manual inputs from the pilot for about seven minutes, after which time (when at 124 ft altitude) the data-link signal was lost. After 30 seconds without signal, the RPA entered the ‘home’ flight mode, and began tracking to the incorrectly programmed home position at an altitude of 154 ft.

The RPA did not respond to control inputs made by the pilot, and the pilot subsequently lost sight of the RPA which was travelling out to sea. The RPA was not found despite an extensive search.

The south-eastern point used to georeference the image on the ground control station map was selected to a northern hemisphere latitude, which resulted in incorrect waypoints and home position for the mission.

The RPA data-link signal to the ground control station was lost, so it began tracking to the incorrectly programmed home position, which was in the Coral Sea Islands about 1,200 km north of the start position.

Safety message

Australian Transport Safety Bureau Chief Commissioner Greg Hood says incorrect reference data can have potentially serious consequences in remotely piloted and manned aircraft. “RPAS operators should expect data loss events and prepare for these appropriately,” Mr Hood said.

“It is imperative that remotely piloted aircraft systems incorporate means of minimising the opportunity for errors to occur and also for detecting and correcting errors that do occur.

“The careful application of operational controls and procedures, underpinned by robust risk assessment, will become increasingly important as relevant technologies develop further and new remotely piloted aircraft systems (RPAS) applications continue to emerge.”

Mr Hood says the ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns relates to data input errors.
Read the investigation report AO-2016-128
 



Last update 06 February 2017 

I am not doubting the integrity and importance of the Chief Commissioner Hood delivered 'safety message'. However I find it passing strange that Hoody a) put such priority on this 'safety message' as to have it delivered via a formal media release ... ; and b) why Hoody felt the need to deliver this something, nothing investigation himself...  

Perhaps with the upcoming drone inquiry he wants the ATSB to be seen to be more proactive on addressing developing UAV/RPA safety issues? Or perhaps he is a bit sensitive about the fact the CASA did not consult/request the transport safety bureau to conduct drone safety research to support the safety case for last year's CASR Part 101 amendments...

Question no.: 204

Program: n/a

Division/Agency: Australian Transport Safety Bureau

Topic: Drone regulation changes

Proof Hansard Page: Written

Senator Xenophon, Nick asked:

Noting the current consideration with respect to Drone regulation changes, what data did ATSB provide CASA with respect to Drones incidents and accidents?

a) Was this data provided to the Minister?

b) Was this data provided to any MPs in the recent briefing to MPs and Senators on the Drone regulations?

Answer:

The ATSB did not provide CASA with any data regarding drone incidents and accidents.

a) n/a

b) n/a

     
3. Finally I noted another presser from the ATSB released last Friday:

Chief Pilots land in Canberra

Chief Pilots from around Australia converged on the ATSB’s office in Canberra today to take part in the national Chief Pilots’ forum.

The Group of Chief Pilots from the majority of Australia’s high capacity carriers meet on a regular basis to discuss safety-related issues. (High capacity aircraft are those certificated as having a maximum seating capacity exceeding 38 seats or a maximum payload exceeding 4200 kilograms.)

The forum encourages the ongoing, effective relationship with industry stakeholders and regulators. The primary aim of the forum is to enhance aviation safety.

Each airline Chief Pilot usually hosts the forum at their corporate office. While today’s forum is hosted by Virgin Australia Regional Airlines, the group will meet at the ATSB to discuss transport safety notifications and occurrence reporting as well as aviation regulatory matters.

ATSB Chief Commissioner Greg Hood will also provide an overview of how the national transport safety investigator is evolving to meet a host of new challenges within the aviation industry.

Program participants will have an opportunity to tour the ATSB’s technical facilities where investigators analyse Cockpit Voice Recorder and Flight Data Recorder readouts for occurrences in Australia and overseas. Australia is one of few countries in the Asia-Pacific region to possess these types of labs.


 



Last update 03 February 2017 

 Easily a couple hundred years of aviation flying experience in that lot, great initiative...

"..Each airline Chief Pilot usually hosts the forum at their corporate office. While today’s forum is hosted by Virgin Australia Regional Airlines, the group will meet at the ATSB to discuss transport safety notifications and occurrence reporting as well as aviation regulatory matters.."

Hmm...Q/ Wonder if Hoody provided an update on the rapidly approaching 3 year VARA ATR Birdstrike/pitch disconnect accident investigation?  (Reference: World's best practice in CYA Aviation Accident Investigation)



MTF...P2

Ps Q/ Do you think Hoody has a few issues with prioritising investigations and micro-managing??

[Peetwo]

When we've got GT who needs the ATSB?-

Reference from 'Accidents - Domestic' thread:

Second coffee speculative.

“When Hansard do their thing we will take a closer look at just who is responsible for what; but CASA have made it clear they are, so far as they are concerned – off the hook.”

Can anyone spot the pattern emerging?  The CASA has identified one of the very real causal chain links and are moving the spotlight away from that area. Senator Back (bless) has very nearly tumbled to it; close but, no cigar.

Carmody spells out the CASA concerns – the operational area approved, “the box”, was the amount of airspace allocated too restrictive? Now, to be fair we cannot blame the CASA for this; well not for all of it.  Say you were flying the display aircraft and CASA gave you an area to work within – for crowd safety reason. You look at the sketch (map or whatever) and note that you only have room to turn onto a base leg which will place you on say (for sake of a number) on a half final; it’s far too tight. So you then negotiate an alternative; minimum height, speed and distance required for a ‘stable’ approach; CASA can make an exception to allow this. It is called command discretion, or operational control. I doubt that the CASA officer issuing the ‘permit’ knows the aircraft performance requirements, probably not even type rated; part of his job is to ensure crowd safety, which requires a ‘safety area’ to be defined and enforced. If the space is too small, ultimately it is the pilots responsibility to ensure an extension, exemption, or cancel if a suitable compromise cannot be achieved. I’d bet my hat this never happened.

But, it is fairly human to simply accept the boundaries imposed, particularly CASA enforced ones.. I am starting to think the Mallard accident was, very much, a Human Factors classic. You can see the picture; dead keen to participate; delays in approval, licence and rating hassles, organisers needing to do there thing; a hundred minor details to sort out; and the subconscious anxiety. To ‘stuff it up’ by getting outside the steel rules and loosing the hard won approval and, possibly, landing in hot water with CASA would weigh on the mind. Particularly for an ‘inexperienced’, newly fledged display pilot.

I wonder if the ATSB will examine how much ‘practice’ was done to ensure that the aircraft could be operated within the approved area? Normally, with any sort of medium weight multi engine aircraft a three mile final approach leg from 1500 feet is a ‘routine’ breeze; two miles from 1000 feet is a very acceptable stroll in the park; and a one mile final from500 feet is routinely doable- student pilots do it all day long; but much less distance than that is approaching the ‘risky’ if the aircraft is not configured and stable.

This all leaves us with a mosaic, a jigsaw puzzle to fit together. One piece which must be acknowledged is the ‘fear’ of CASA reprisal and punishment for getting ‘outside’ of the black and white law as specified. Perhaps CASA would not have penalised, punished or prosecuted had the aircraft strayed from the mandated area; the option to ‘go around’ and return for a second shot was always available – as was abandoning the exercise. Why did the pilot persist is the question we need answered, the answer to that question remains in the Swan. But if we can remove even one of the ‘causal chain’ elements perhaps this accident will not be repeated.

Aye, ‘tis a pretty puzzle; I’ll leave the closing remarks to the CASA - CEO/DAS.

Toot toot.

Better late than never, yesterday the ATSB released their preliminary report into the Swan River 'Sky Works' Mallard fatal accident:

Preliminary

On 26 January 2017, the pilot of a Grumman American Aviation Corp G-73 amphibian aircraft, registered VH‑CQA (CQA), was participating in an air display as part of the City of Perth Australia Day Skyworks event. On board were the pilot and a passenger. The weather was fine with a recorded wind of about 20 km/hr from the south-west and a temperature of about 39 °C.

The pilot of CQA was flying ‘in company’ with a Cessna Caravan amphibian and conducted a series of circuits that included low-level fly-pasts of the Langley Park foreshore (Figure 1). After the second fly-past, the pilot of CQA commenced a third circuit, while the Caravan departed the area.

Figure 1: CQA air display flight track, showing the first fly-past in yellow, the second in magenta and the third in red

Source: OzRunways Pty. Ltd., modified by the ATSB

As part of the third circuit, the pilot of CQA flew in an easterly direction, parallel with the South Perth foreshore, before commencing a left turn. This would have facilitated a third pass in a westerly direction along the Langley Park foreshore. During the left turn, CQA rolled left and pitched nose down, consistent with an aerodynamic stall[1] (Figure 2). The aircraft collided with the water and broke up. The pilot and passenger were fatally injured.

Figure 2: CQA just prior to the collision with water (looking north)

Source: Mike Graham

The ATSB completed the on-site phase of its investigation on 4 February 2017. No pre-existing aircraft defects, which may have contributed to the collision with water, were identified. The ATSB has retained several items and components from the aircraft for further examination. This includes a fuel totaliser, a navigation unit and a mobile phone.

The investigation is continuing and will include:

• examination of numerous witness reports and images and a significant quantity of video footage taken on the day by members of the public, media outlets and so on
  
• review of the aircraft’s maintenance records, operational records for recent flights and pilot training records
  
• review of the meteorological conditions at the time
  
• an examination of aircraft performance and other operational factors
  
• further examination of the recorded flight radar, radio and Global Positioning System data
  
• review of the planning, approval and oversight of the air display, including a focus on safety and risk management practices.
  

Should any critical safety issues emerge during the course of the investigation, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations. This will allow those authorities and organisations to consider safety action to address the safety issues. Details of such safety issues and any safety action in response will be published on the ATSB website at www.atsb.gov.au.
 
______________
The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.
 
__________

1. Aerodynamic stall: occurs when the airflow separates from the wing’s upper surface and becomes turbulent. A stall occurs at high angles of attack, typically 16˚ to 18˚, and results in reduced lift.
   

 
Initial
Updated: 30 January 2017
The ATSB has deployed two additional specialists to investigate the collision with water involving Grumman American Aviation Corp G-73, registered VH-CQA, on 26 January 2017.

A Licensed Aircraft Maintenance Engineer (LAME) and a Human Factors specialist have arrived from Canberra to join the ATSB team in Perth.

The investigation will continue in detail, seeking information and data on meteorological conditions on the day, as well as examining pilot and maintenance documentation.

The ATSB will also seek recorded radar and radio information from AirServices Australia.

The ATSB has assisted the WA Department of Transport (Marine) recover the wreckage to enable the investigation to continue. The investigation may take up to a year to complete.

The ATSB is grateful to the many witnesses who have provided written, photographic and video evidence of the aircraft immediately prior to, during and after the accident. Investigators will contact witnesses as soon as they are able. 
 
Published: 27 January 2017


The ATSB is investigation the collision with water involving Grumman American Aviation Corp G-73, registered VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017.

While overflying the Swan River near the Perth CBD, the aircraft crashed into water destroying the aircraft and resulting in fatal injuries to the pilot and one passenger.

The ATSB deployed two investigators who arrived at the accident site during the afternoon of Thursday 26 January 2017. Over the next few days they will examine the accident site, interview witnesses, and collect maintenance and pilot records, and air traffic control recorded data.

The investigators are seeking witness reports and video recordings that might assist the investigation. Witnesses are requested to contact the ATSB on 1800 020 616 or email ATSBinfo@atsb.gov.au.
 
General details

General details Date: 26 Jan 2017
 
Investigation status:
Active
 
Time: 17:08 WST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Swan River, Perth
 
Occurrence type: Collision with terrain
 
State: Western Australia
 
Occurrence class:
Operational
 
Release date: 08 Mar 2017
 
Occurrence category: Accident
 
Report status: Pending
 
Highest injury level: Fatal
 
Expected completion: Jan 2018 
 
Aircraft details

Aircraft details/Aircraft manufacturer: Grumman American Aviation Corp
 
Aircraft model: G-73 Mallard (amphibious)
 
Aircraft registration: VH-CQA
 
Type of operation: Aerial Work
 
Damage to aircraft: Destroyed 
 
 


Last update 08 March 2017

The release of the ATSB prelim report was followed closely by a review from resident WA AAI expert and media commentator GT in PerthNow... :

What caused the Swan River seaplane crash on Australia Day
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/921fcf883480b34f15f1f7c0c700dba9?esi=true&t_template=s3/chronicle-tg_tlc_storyheader/index&t_product=PerthNow&td_device=desktop[/img]Geoffrey Thomas, PerthNow
March 8, 2017 9:55pm
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/article/921fcf883480b34f15f1f7c0c700dba9?esi=true&t_template=s3/chronicle-tg_tlc_storymeta/index&t_product=PerthNow&td_device=desktop[/img]
AUSTRALIA'S crash investigator says that the Grumman G-73 Mallard that crashed into the Swan River in front of thousands of spectators celebrating Australia Day suffered an aerodynamic stall.

Father-of-three Peter Lynch, 52, and Endah Cakrawati, 30, died when the twin-engine Mallard stalled during a tight turn and plunged nose first into the river.

Mr Lynch had owned the plane since 2011 and had spent more than 120 hours at the controls.

But as a newcomer to Perth, he had never before attempted to land it on the river.
He has expressed concerns about the flying display he was take part in because of the lack of wind and the heat which would have impacted the plane’s performance.

Those conditions required a higher speed and in this case deployment of the aircraft’s flaps which increase the wing’s lift.

However the flaps were not activated.

The ATSB said that the wind was about 20 km/hr from the south-west and the temperature was about 39 °C.
The sequence of the Swan River crash. Pictures: Twitter / Vicki Clark

When the plane crashed it was travelling north-east so the 20km/hr south-west wind would have worsened the situation by affectively reducing his over-the-wing-speed by 20km/hr.

The ATSB said it found no pre-existing aircraft defects, which may have contributed to the collision with water.

However the ATSB has retained several items and components from the aircraft for further examination.

These include a fuel totaliser, a navigation unit and a mobile phone.

Hmm...wonder how much GT charges for top cover 'the pilot did it' investigative reports? Maybe Hoody can farm out some of his outstanding backlog of AAI's to GT - for a small fee of course...

MTF...P2

[Gobbledock]

Mr Thomas is a bottom dwelling parasite. He makes his money by cutting and pasting from other peoples work and then sticking his name at the bottom. He knows no more about real aviation than Chester does. Both are worthless pieces of shit.

Ta ta

[Peetwo]

Two+ years for this?  - AO-2015-032 Investigation status: Completed

Summary & findings:

What happened

On 14 March 2015 Malaysia Airlines Airbus A330, registered 9M-MTA, began its approach to Melbourne (Tullamarine) after a flight from Kuala Lumpur. In the final stages of the approach, at approximately 50 feet, the captain reported feeling the aircraft sink and manually increased the thrust to the engines in an attempt to slow the rate of descent. Despite this action, the aircraft experienced a hard landing of a magnitude requiring replacement of the aircraft’s main landing gear. There were no reported injuries as a result of the occurrence.

What the ATSB found

The ATSB found that as a result of the pilot flying’s control inputs after disengaging the autopilot (approximately 700 feet above the ground), the final approach had become unstable, descending below the desired vertical profile. The continuation of the approach and an inappropriate attempt to recover the situation led to a high rate of descent at touch down.

What has been done as a result

Soon after the event, the operator circulated a memorandum to their A330 flight crew highlighting the incident and advising of the relevant procedures intended to minimise the chances of a similar occurrence. The flight crew involved also undertook additional training and assessment before returning to flight duties.

Safety message

A stable approach significantly reduces the risk of a hard landing.

If an approach does become unstable, a rushed attempt to recover the approach may produce an undesirable aircraft response. There is also a risk of breaking down the shared understanding between the pilots, which in turn limits the opportunity of the other flight crew to detect or react to inappropriate actions.

When landing, pilots should maintain a safety philosophy of “if in doubt, go around”.

---

Findings

From the evidence available, the following findings are made about the hard landing involving an Airbus A330-343, registered 9M-MTA that occurred at Melbourne Airport, Victoria on 15 March 2015. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Contributing factors

• The final approach became unstable at around 300 feet above the ground due to the control inputs from the captain.
  
• Inadequate monitoring and communication by the crew led to a lack of recognition of the undesirable flight state and the continuation of an unstable approach.
  
• Continuation of the unstable approach led to a high rate of descent at touchdown and resulted in a hard landing in excess of the aircraft design loads and short of the normal touchdown area.
  

Other safety factors

• The captain used an unapproved manual thrust procedure in an attempt to recover the approach.
  

 Bearing in mind there is a PAIN BRB review pending but at 1st glance I have to ask WTD was the hold-up? Maybe the PC commissioners were waiting for diplomatic approval to quietly release what had the potential to be a serious accident...  


MTF...P2

Ps Still waiting for the 3rd anniversary interim report for the VARA ATR broken tail accident investigation, that saw a VARA ATR flying for 5 days and 13 additional sectors since the horizontal stabiliser was initially structurally damaged.     

The ATSB reported: "The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser."

[Peetwo]

Update: 2nd interim report & safety recommendation to ATR  

..Still waiting for the 3rd anniversary interim report for the VARA ATR broken tail accident investigation, that saw a VARA ATR flying for 5 days and 13 additional sectors since the horizontal stabiliser was initially structurally damaged.     

The ATSB reported: "The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser."

Released today by the ATSB is a pretty serious update (2nd interim report) to the VARA ATR pitch disconnect investigation, that includes a SR addressed to ATR...  

Download Interim Report 2
[DownloadPDF: 1.16MB] ;or  

Alternate: [DownloadDOCX: 1.64MB] 

[i][b]Second interim report - published: 5 May 2017
[/b][/i]
On 20 February 2014, a Virgin Australia Regional Airlines (VARA) ATR 72 aircraft, registered VH‑FVR, operating on a scheduled passenger flight from Canberra, Australian Capital Territory to Sydney, New South Wales sustained a pitch disconnect while on descent into Sydney. The pitch disconnect occurred while the crew were attempting to prevent the airspeed from exceeding the maximum permitted airspeed (VMO). The aircraft was significantly damaged during the occurrence.

In accordance with the Transport Safety Investigation Act 2003 (the Act), the ATSB initiated an investigation into the occurrence. On 15 June 2016 the ATSB released its first interim investigation report that contained the following safety issue:

• Inadvertent[1] application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
  

In the interest of transport safety, this safety issue was brought to the attention of the aircraft manufacturer (ATR) and the wider aviation industry prior to completion of the investigation.

During the continued investigation of the occurrence, the ATSB has obtained an increased understanding of the factors behind this previously identified safety issue. This increased understanding has identified that there are transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads that could exceed the strength of the aircraft structure.

The ATSB also found that these transient elevator deflections were not identified, and therefore not considered in the engineering justification documents completed during the aircraft type’s original certification process. The ATSB considers that the potential consequences are sufficiently important to release a further interim report prior to completion of the final investigation report.

This second interim report expands on information already provided in, and should be read in conjunction with, the interim report released on 15 June 2016 report and an update on the ATSB website on 10 June 2014.[2] It is released in accordance with section 25 of the Act and relates to the ongoing investigation of the occurrence.

Readers are cautioned that the factual information and analysis presented in this interim report pertains only to the safety issue discussed herein. The final report will contain information on many other facets of the investigation, including the operational, maintenance, training and regulatory aspects.

Readers are also cautioned that new evidence may become available as the investigation progresses that will enhance the ATSB’s understanding of the occurrence. However, in order to ensure the veracity of the analysis of the evidence leading to the identified safety issue, the ATSB engaged the UK Air Accidents Investigation Branch (AAIB) to conduct a peer review. The AAIB conducted an analysis of the evidence relating to the safety issue and concluded that their findings were consistent with those provided by the ATSB.
__________

1. In the context of this safety issue, ‘inadvertent’ is taken to mean that the opposing pitch control inputs were unintended.
   
   
2. www.atsb.gov.au/publications/investigation_reports/2014/aair/ao-2014-032.
   

---

Consideration of transient elevator deflections from a pitch disconnect
Issue number:
AO-2014-032-SI-02
Who it affects:
All operators of ATR 42 and ATR 72 aircraft
Issue owner:
ATR
Operation affected:
Aviation: Air transport
Background:
Investigation Report AO-2014-032
Date:
05 May 2017

Safety issue description
The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect.

Application of the safety issue to both ATR 42 and 72 models

Although the flight control system in the ATR 72 has been assessed in this report, the ATR 72 is a longer version of the ATR 42 and the design of the flight control system is common to both models. The different length of the control runs is likely to have an effect on the flexibility, but the uncertainty that results from the lack of detailed engineering assessment means that the safety issue also applies to the ATR 42 model.

Initial safety action taken by the ATSB

On 11 November 2016, the ATSB notified ATR of the concerns identified in this report. The ATSB also notified the Australian operator of the aircraft, the Civil Aviation Safety Authority and the Federal Department of Infrastructure and Regional Development.
The issue was further discussed with ATR at meetings on 18 November 2016 and 1 December 2016. The European Aviation Safety Agency was also present during those meetings.

Recommendation
Action organisation:
Civil Aviation Safety Authority
Action number:
AO-2014-032-SR-016
Date:
05 May 2017
Action status:
Monitor

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

Recommendation
Action organisation:
European Aviation Safety Agency
Action number:
AO-2014-032-SR-015
Date:
05 May 2017
Action status:
Monitor

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

Recommendation
Action organisation:
ATR
Action number:
AO-2014-032-SR-014
Date:
05 May 2017
Action status:
Monitor

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

Proactive Action
Action organisation:
ATR
Date:
05 May 2017
Action status:
Released
On 1 December 2016, in response to the identified safety issue, ATR advised the ATSB that they intended to:

• perform a risk assessment to determine the short term risks associated with continued operation
  
• conduct a detailed engineering analysis of the transient elevator loads during a pitch disconnect.
  

Short term risk assessment

On 15 December 2016, ATR provided the ATSB with the results of their assessment of the short term risks of continued operation awaiting the complete engineering work associated with the issue. Their assessment concluded that:

ATR considers that continued safe operation is ensured by considering

• In the jamming situation, the ultimate loads cannot be exceeded through the control column input (excessive effort and mechanical stops). At high speed, the differential elevator deflection has margin to accommodate the transient load.
  
• The probability of a repeat occurrence of the MSN1058 [VH-FVR] event defeating all the barriers inherent in the design and standard operating procedures.
  
• The quantitative analysis results showing no immediate action is required.
  

Detailed engineering analysis of transient elevator deflections

On 11 April 2017, ATR provided the ATSB with an update on the detailed engineering analysis of the transient elevator loads. The briefing included an overview of the analysis methodology and preliminary results.

The analysis being conducted is based upon an analytical model supported by both ground and flight testing. The analytical model represents the ATR pitch control system and has system component masses and stiffness represented as group blocks. This includes a block representing the pitch uncoupling mechanism (PUM), which was modelled to represent the behaviour of the PUM before, during and after activation.

ATR has compared the model to the behaviour of the system recorded during ground test and has identified a favourable correlation. The results of the model showed that, following activation of the PUM on the ground, without aerodynamic loads, the flight control system responded in an underdamped oscillatory manner.

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

ATR are continuing with the detailed analysis. Further work includes:

• Flight testing to determine a suitably realistic pilot response to activation of the PUM
  
• Verification of the analytical model with data recorded during the flight tests
  
• Modelling of the dual input case
  
• Modelling of other cases required by the European Aviation Safety Agency.
  

ATSB response:
The ATSB acknowledges the efforts of ATR to resolve the safety issue. The ATSB also notes that, while the short‑term risk assessment does not account for the transient elevator deflections associated with a pitch disconnect, until the results of the detailed engineering analysis are available it is not possible to accurately quantify the transient elevator loads. Consequently, it is not possible to fully determine the magnitude of the risk associated with continued operation of ATR42/72 aircraft until the engineering analysis is complete.
Noting the above, the ATSB’s retains a level of ongoing concern as to whether the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect. Consequently, while the ATSB accepts that the current level of safety action partially addresses the safety issue; the ATSB makes the following safety recommendations.
 
 
Current issue status: Safety action pending
Status justification:
The ATSB acknowledges the efforts of ATR with regard to the detailed engineering analysis of the transient elevator deflections. The preliminary results have shown that the system responds in an underdamped oscillatory manner, resulting in elevator deflections greater than those identified by the static analysis previously carried out by ATR. The ATSB is encouraged by the level of detail into which ATR have developed the analysis and will continue to monitor their progress. Until such time that the analysis has satisfactorily shown that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect, the identified safety issue will remain open.
 


Last update 05 May 2017

Still much..much MTF on this one me thinks...

P2...
 
Ps "..However, in order to ensure the veracity of the analysis of the evidence leading to the identified safety issue, the ATSB engaged the UK Air Accidents Investigation Branch (AAIB) to conduct a peer review. The AAIB conducted an analysis of the evidence relating to the safety issue and concluded that their findings were consistent with those provided by the ATSB..." - Q/  The ATSB get the AAIB to peer review their findings in this more than 3 year investigation, does this mean they will be doing the same for the PelAir re-investigation? - just saying...

[Sidebar]

"does this mean they will be doing the same for the PelAir re-investigation?"

Nope, going to ask the Canadians again.

Hello folks, I'm a longtime lurker here. The whole Pel-Air saga has been quite interesting to follow, and I'm impatiently waiting for the re-investigation report to come out followed by whatever uproar occurs.

I quite enjoy the videos from the Senate estimates committee; in contrast, Canadian officials don't seem to be called to testify on a regular basis.

[Kharon]

Tactful of toothless?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 
Toot – sigh – toot.