04-04-2017, 07:15 AM
Yep, let's all get moving to quickly cover our asses even while 5 bodies remain smouldering in the fragmented wreckage.....wonderful example of humans caring about other humans.
(02-23-2017, 08:45 PM)Peetwo Wrote: References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:Dick & 'that man' in the Oz today.. :
(09-17-2015, 08:17 AM)Peetwo Wrote:
Them holes are aligning
Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering, aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...
Courtesy the Oz:
Quote:Near miss for planes carrying 18 people
- Too close for comfort. Source: TheAustralian
Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:
(02-23-2017, 07:23 AM)Peetwo Wrote:Quote:Air safety bodies spoke ‘more than once’ on pilot’s near-miss
Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images
...ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.
An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.
“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed...
On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13:
Quote:Australia requires reporting of ‘transport safety matters’, which, through definitions
and reporting requirements in the Transport Safety Investigation Act 2003 and Transport
Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.
Okay what I think the ATSB notified difference to ICAO Annex 13 on the definition of a 'serious incident' means, is that the ATSB can (read will) effectively abrogate all responsibility to investigate all 'serious incidents' under the spirit, intent and compliance of the Annex...
Therefore the ATSB practice of O&O'ing some potentially DIP sensitive 'serious incident' investigations has become a normalised SOP.
In the case of the MT Hotham 'near miss' investigation the delay can be (& probably will be) excused because the regulator CASA has conducted proactive safety risk mitigation by testing, re-testing and overseeing the proficiency checks of the incident pilot. The ATSB only need say that safety risk was being effectively mitigated.
However it is 'passing strange' that nowhere within the AO-2015-108 investigation webpage does the ATSB indicate that they have identified a 'safety issue' (i.e pilot proficiency) that they have subsequently sent to CASA to be proactively addressed. Nor is there any indication of any form of Annex 13 required 'interim report' on the 1st anniversary of the ATSB defined 'serious incident' investigation...
On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE.
Quote:Quote:Report ‘may have stopped crash’
12:00amEAN HIGGINS
A safety report ‘may have prevented’ tragedy that saw five die when a plane crashed into a Melbourne shopping centre.
An 18-month-old investigation into the pilot involved in February’s Essendon plane crash, which killed five people, will not be made public until June, sparking criticism from a former air safety chief that this year’s tragedy may have been avoided had the earlier probe been finalised.
The Australian Transport Safety Bureau is only now in the process of finalising its investigation into a near mid-air collision in 2015 which involved pilot Max Quartermain, who died with four passengers near Melbourne’s Essendon airport in February.
Dick Smith, a former chairman of the Civil Aviation Safety Authority, said it was “completely inexcusable” that the ATSB had still not completed the report of its investigation of the September 2015 incident at Mount Hotham.
He told The Australian that had the ATSB completed its investigation and report within a reasonable timeframe, and concluded that pilot Quartermain had engaged in poor airmanship endangering lives, he might have been grounded.
In that case, Mr Smith said, Quartermain would not have piloted February’s flight in which he and four American passengers died when the Beechcraft King Air crashed into a shopping centre nine seconds after it took off from Essendon airport. The ATSB, in its initial determination of the Essendon disaster, could find no evidence of catastrophic engine failure in the King Air.
Although aviation experts said this did not exclude the possibility of engine problems due to other causes, such as fuel contamination, it has turned further attention to possible pilot error.
- Fatal pilot probed over near-miss Chip Le Grand, PIA AKERMAN, JOHN FERGUSON
- Mystery clouds Essendon crash SIMONE FOX KOOB
The ATSB launched its Mount Hotham investigation after a pilot claimed that Quartermain, flying a King Air from Melbourne, had confused other pilots in his radio communications and nearly crashed into his aircraft as they both were preparing to land.
Quartermain was flying corporate officials from Audi to an event at the alpine resort when, investigators determined, he came within 1.8km horizontally and 90m vertically of a King Air flying from Sydney, transporting passengers to the same function.
At one point, it was alleged, Quartermain radioed to say he was 10 nautical miles west of Mount Hotham, before correcting himself to say he was actually 10 nautical miles east.
Some passengers were so unnerved by the experience they refused to fly back to Melbourne with Quartermain, forcing the charter company to send another pilot.
In his complaint to the ATSB, the pilot of the other King Air said: “If this event did result in a mid-air collision, two aircraft would have been destroyed and 18 people would have been killed.” The ATSB report into the Mount Hotham incident has been repeatedly delayed.
An ATSB spokesman said that report was expected to be made public in June, and that the delay reflected a large number of fatal accidents and serious incidents over the past six months, which “required re-prioritisation of limited investigator resources.”
The spokesman said the ATSB would always publicly release findings of “critical safety issues” as they were discovered rather than wait for a final report, and added, “it is not a function of the ATSB to apportion blame for transport safety matters”.
That function fell to the Civil Aviation Safety Authority.
(04-10-2017, 08:13 AM)Peetwo Wrote: Re-hash courtesy of ATSB Aberration thread O&O :
(02-23-2017, 08:45 PM)Peetwo Wrote: References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:Dick & 'that man' in the Oz today.. :
(09-17-2015, 08:17 AM)Peetwo Wrote:
Them holes are aligning
Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering, aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...
Courtesy the Oz:
Quote:Near miss for planes carrying 18 people
- Too close for comfort. Source: TheAustralian
Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:
(02-23-2017, 07:23 AM)Peetwo Wrote:Quote:Air safety bodies spoke ‘more than once’ on pilot’s near-miss
Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images
...ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.
An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.
“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed...
On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13:
Quote:Australia requires reporting of ‘transport safety matters’, which, through definitions
and reporting requirements in the Transport Safety Investigation Act 2003 and Transport
Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.
Okay what I think the ATSB notified difference to ICAO Annex 13 on the definition of a 'serious incident' means, is that the ATSB can (read will) effectively abrogate all responsibility to investigate all 'serious incidents' under the spirit, intent and compliance of the Annex...
Therefore the ATSB practice of O&O'ing some potentially DIP sensitive 'serious incident' investigations has become a normalised SOP.
In the case of the MT Hotham 'near miss' investigation the delay can be (& probably will be) excused because the regulator CASA has conducted proactive safety risk mitigation by testing, re-testing and overseeing the proficiency checks of the incident pilot. The ATSB only need say that safety risk was being effectively mitigated.
However it is 'passing strange' that nowhere within the AO-2015-108 investigation webpage does the ATSB indicate that they have identified a 'safety issue' (i.e pilot proficiency) that they have subsequently sent to CASA to be proactively addressed. Nor is there any indication of any form of Annex 13 required 'interim report' on the 1st anniversary of the ATSB defined 'serious incident' investigation...
On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE.
Quote:Quote:Report ‘may have stopped crash’
12:00amEAN HIGGINS
A safety report ‘may have prevented’ tragedy that saw five die when a plane crashed into a Melbourne shopping centre.
An 18-month-old investigation into the pilot involved in February’s Essendon plane crash, which killed five people, will not be made public until June, sparking criticism from a former air safety chief that this year’s tragedy may have been avoided had the earlier probe been finalised.
The Australian Transport Safety Bureau is only now in the process of finalising its investigation into a near mid-air collision in 2015 which involved pilot Max Quartermain, who died with four passengers near Melbourne’s Essendon airport in February.
Dick Smith, a former chairman of the Civil Aviation Safety Authority, said it was “completely inexcusable” that the ATSB had still not completed the report of its investigation of the September 2015 incident at Mount Hotham.
He told The Australian that had the ATSB completed its investigation and report within a reasonable timeframe, and concluded that pilot Quartermain had engaged in poor airmanship endangering lives, he might have been grounded.
In that case, Mr Smith said, Quartermain would not have piloted February’s flight in which he and four American passengers died when the Beechcraft King Air crashed into a shopping centre nine seconds after it took off from Essendon airport. The ATSB, in its initial determination of the Essendon disaster, could find no evidence of catastrophic engine failure in the King Air.
Although aviation experts said this did not exclude the possibility of engine problems due to other causes, such as fuel contamination, it has turned further attention to possible pilot error.
- Fatal pilot probed over near-miss Chip Le Grand, PIA AKERMAN, JOHN FERGUSON
- Mystery clouds Essendon crash SIMONE FOX KOOB
The ATSB launched its Mount Hotham investigation after a pilot claimed that Quartermain, flying a King Air from Melbourne, had confused other pilots in his radio communications and nearly crashed into his aircraft as they both were preparing to land.
Quartermain was flying corporate officials from Audi to an event at the alpine resort when, investigators determined, he came within 1.8km horizontally and 90m vertically of a King Air flying from Sydney, transporting passengers to the same function.
At one point, it was alleged, Quartermain radioed to say he was 10 nautical miles west of Mount Hotham, before correcting himself to say he was actually 10 nautical miles east.
Some passengers were so unnerved by the experience they refused to fly back to Melbourne with Quartermain, forcing the charter company to send another pilot.
In his complaint to the ATSB, the pilot of the other King Air said: “If this event did result in a mid-air collision, two aircraft would have been destroyed and 18 people would have been killed.” The ATSB report into the Mount Hotham incident has been repeatedly delayed.
An ATSB spokesman said that report was expected to be made public in June, and that the delay reflected a large number of fatal accidents and serious incidents over the past six months, which “required re-prioritisation of limited investigator resources.”
The spokesman said the ATSB would always publicly release findings of “critical safety issues” as they were discovered rather than wait for a final report, and added, “it is not a function of the ATSB to apportion blame for transport safety matters”.
That function fell to the Civil Aviation Safety Authority.
..."it is not a function of the ATSB to apportion blame for transport safety matters”... - Nor is it the function of a supposedly ICAO Annex 13 compliant AAI to provide top-cover support for the regulator CASA and/or the ATC service provider ASA...
Hmm...wonder how long it will be before Hoody again has a sook and makes another addition to the ATSB's BS 'correcting the bollocks' page - TICK...TOCK indeed...
Quote:Essendon DFO plane crash: Investigators work to unravel web of companies behind doomed flight
The complex corporate structure behind a plane that crashed at Essendon airport has left authorities scrambling to establish who was responsible for the doomed flight.
- [/url]Liam Mannix
- [url=http://www.theage.com.au/victoria/by/Tom-Cowie-hvf7w]Tom Cowie
The opaque web has raised serious concerns about the flight's insurance coverage and the legal entity that will eventually be held to account for the February crash.
The DFO and the wreckage from the doomed flight. This image is taken from an ATSB report into the crash. Photo: ATSB
At least three large law firms are preparing legal action on behalf of the victims.
Separate entities owned the plane, operated it, flew it, maintained it and chartered it.
This image shows the collision between the flight and the DFO Photo: ATSB
Adding to the confusion, the B200 Super King Air was registered to yet another company just a week before it crashed into the Essendon DFO shopping centre.
Paul O'Brien, managing director at AVMIN, one of Australia's largest charter-flight bookers, says involving six different companies in a single flight blurred the lines of responsibility.
"Accidents will occur, but there have to be some procedures in place that ensure that if there is, you are covered insurance-wise," he says.
Mr O'Brien said many small charter companies held the minimum insurance required, which is $725,000 per passenger according to the Civil Aviation Safety Authority.
Aircraft track from Airservices Australia data. Photo: ATSB
Another aviation source said the mandatory amount was "laughable".
The question over who was responsible for the flight is still being investigated by the Australian Transport Safety Bureau.
For unknown reasons, the cockpit voice recorder failed to capture the doomed flight Photo: ATSB
Records show the owner of the plane VH-ZCR is Bendigo based-company BB1544. Its sole director is businessman Christopher Richards.
Dr Richards is also behind the company MyJet Aviation Services, which transferred the operation of the plane to Australia Corporate Jet Centres (ACJC) in the weeks leading up to the crash.
The operator is in charge of maintenance and airworthiness of a flight, according to the Civil Aviation Safety Authority.
Dr Richards declined to comment.
ACJC was told by CASA hours after the plane had crashed that it had been registered in its name five days earlier.
An administrative bungle over an incorrect credit card expiry date recently led to a legal fight over ACJC becoming the registered operator.
"This is the flavour of general aviation in this country, it's a hotchpotch," said aviation safety expert Neil Hansford.
It remains unclear whose air operator's certificate was being used to conduct the flight. The air operator's certificate authorises someone to fly for "hire and reward" but also carries potential liability.
ACJC has claimed Max Quartermain's company Corporate & Leisure Aviation leased the plane from MyJet and flew it under his own air operator's certificate.
Mr Quartermain's certificate was still current when the plane smashed into the shopping centre, however MyJet's authorisation had expired.
The flight itself was booked through tour-company GolfSELECT, which declined to comment last week. Golf trips to King Island and then Barnbougle Dunes in Tasmania cost $2500 per person, according to its website.
It is understood yet another company called Interair was hired to maintain the plane. The company continued to service the plane despite the administrative bungle over its registered operator.
When the families will actually get answers about what went wrong is unclear.
The Australian Transport Safety Bureau is behind on most of its investigations, finalising just 30 per cent of complex cases within 12 months in 2015-16 — well below the legislated requirement of 90 per cent.
Mr Hansford says the delay was related to Australia taking a lead role in the complicated MH370 investigation and the compounding effect that has had on the rest of the agency's work.
Flight MH370 disappeared on March 8, 2014 while flying from Kuala Lumpur to Beijing.
"It was a massive task, the Americans would have had problems coping with a crash of that type," he says.
What may hasten the Essendon investigation is the involvement of US authorities like the Federal Aviation Administration, which has been brought in to help.
Lawyers are also circling what could end up developing into a multimillion-dollar lawsuit.
There is also the potential for US attorneys to become involved, after the death of high-profile Texan lawyer Russell Munsch and three other wealthy Americans in the crash.
Maurice Blackburn's aviation law expert Joseph Wheeler says the questions over who was in charge of the plane would need to be resolved to ensure someone was made liable.
One of the consequences of the crash and the subsequent administrative battle may be a streamlining of CASA's administrative processes, he says.
"The families will not be left without remedy just because of some administrative or other confusion," he says.
(04-13-2017, 06:32 PM)P7_TOM Wrote: The Rex Saab and the missing propeller:-HERE.
Quote:Preliminary report published: 13 April 2017
The occurrence
On 17 March 2017, a Saab 340B aircraft, registered VH-NRX (NRX) was being operated as RXA768 on a routine passenger flight from Albury, New South Wales (NSW) to Sydney, NSW. On board the aircraft were 16 passengers and 3 crew.
About 55 nautical miles south-west of Sydney airport, the crew noticed uncommanded engine indications and began the necessary checklists. While undertaking the checklist items, the crew experienced minor vibrations from the right engine. These vibrations worsened as the checklist progressed and became visually evident to the First Officer.
As a result the crew commenced the engine shutdown procedure. During the engine shutdown procedure, the propeller separated from the aircraft. The crew made a Pan-Pan[1] call to air traffic control, and completed the engine shutdown procedure. The aircraft landed without incident at Sydney airport.
Figure 1: The aircraft, VH-NRX, at Sydney airport after the incident
Source: Grahame Hutchison
An inspection of the aircraft by the ATSB at Sydney airport identified that the propeller shaft had fractured, leading to the separation of the propeller.
On 21 March 2017, the NSW Police Aviation Support Branch (PolAir) undertook a search operation for the separated propeller. The propeller was located in an area under dense forest about 8NM south-west of Sydney airport.
Figure 2: The propeller that had separated from VH-NRX as found by PolAir about 8NM south-west of Sydney airport
Source: ATSB
The propeller was found with the flange section of propeller shaft secured to the propeller assembly and a fracture through the propeller shaft. ATSB subsequently removed the remaining propeller shaft and integral flange section (Figure 4) for examination at its facilities in Canberra.
Propeller shaft examination
The recovered part of the propeller shaft is highlighted in figure 3. The propeller was found properly secured to the forward-facing flange by bolts and the dowel pins pictured. The examination was conducted with representatives present from the Civil Aviation Safety Authority (CASA), SAAB, GE Aviation (engine manufacturer) and Regional Express (REX). Initial observations revealed cracking that appeared to run between the main shaft and the flange region. The part was sectioned in order to expose the crack’s fracture surface.
Figure 3: Propeller gearbox schematic highlighting the recovered section of the propeller shaft
Source: GE Aviation, modified by ATSB
The crack was found to be a fatigue fracture that had initiated within the propeller mounting flange, and then transitioned into the shaft section (see figure 4). The crack originated at the bore of a dowel pin near the forward face of the propeller hub flange. The dowel pin bore was corroded in parts (shown in figure 5), and corrosion pitting was found near the fracture. Further work is ongoing to ascertain whether the corrosion or other factors contributed to the fracture initiation.
Figure 4: Section of the propeller shaft showing the fatigue crack originating at the dowel hole and progressing into the shaft itself
Source: ATSB
This is the first known critical failure of this type initiating within the propeller hub flange of a GE Aviation CT7-9B engine. The same propeller gearbox (PGB) is fitted to multiple variants of the CT7 engine (5A2, 7A1, 9B, 9C, and 9C3) on SAAB 340 and EADS CASA[2] CN-235 aircraft. There is currently no maintenance requirements specified in existing maintenance manuals for routine inspection within the dowel pin bores. Any corrosion or cracking within the bore may go undetected until it progresses to the surface of the flange. Other than a visual inspection of the flange during propeller removal, inspection for surface defects (via magnetic particle inspection or dye penetrant inspection) only occurs when the PGB is disassembled for maintenance at a workshop specifically approved by the engine manufacturer.
Figure 5: Corrosion observed within the bore of the dowel pin hole
Source: ATSB
Safety advisory notice
AO-2017-032-SAN-001:
The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks to their own operation.
Proactive safety action taken by GE Aviation
GE Aviation is actively involved in supporting the Australian Transport Safety Bureau in this investigation. The propeller flange and all required hardware has been transported to GE Aviation laboratories in Cincinnati for further metallurgical analysis.
GE Aviation is inspecting additional PGBs from the fleet and recommends that all operators follow existing maintenance and inspection procedures. As the investigation progresses GE Aviation will release additional maintenance and inspection recommendations if they become necessary.
Proactive safety action taken by Regional Express
Regional Express has quarantined all propeller gearboxes with propeller shafts of the same series as that installed in VH-NRX.
Further investigation
The investigation is continuing and the ATSB will focus on:
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 organisation. 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 .
- maintenance procedures associated with the PGB shaft
- factors that may have contributed to the fatigue fracture at the propeller mounting flange, possibly including:
- design and manufacturing of the dowel pins, bores, and overall assembly
- corrosion protection on the surface of the part
- opportunities for crack detection.
Speedy, sane and in all probability, the right answer - stressed component corrosion?. Well done ATSB, and GE.
Quote:REX propeller fell off because of broken bracket, ATSB report shows
By Kathleen Calderwood
Posted about 6 hours ago
[b]PHOTO:[/b] The propeller was found in bushland in Sydney's outer suburbs. (Supplied: ATSB)
[b]RELATED STORY:[/b] REX flight forced into emergency landing after losing propeller
[b]RELATED STORY:[/b] REX flight forced into emergency landing after losing propeller
[b]MAP: [/b]Sydney 2000
A crack in a crucial mounting bracket was the reason a propeller fell off a Regional Express plane last month, the Australian Transport Safety Bureau has found.
The ATSB released their preliminary report into Flight ZL768, which was forced to make an emergency landing after the right propeller fell off mid air.
The propeller was found a few days later in bushland off the River Road in Revesby in Sydney's south-west.
The ATSB stated a crack had formed in the propeller mounting flange, where the propeller attaches to the gearbox, and moved through to the shaft.
Corrosion was found near the fracture, and the ATSB is continuing their investigations to see whether that contributed to the crack.
ATSB chief commissioner Greg Hood said Regional Express quarantined all propeller gearboxes with the same series of shafts that was in the affected aircraft.
"This is the first known critical failure of this type, initiating within the propeller hub flange of the GE Aviation CT7-9B engine," Mr Hood said.
"Both the operator and the engine manufacturer have already taken proactive safety action in response to the ATSB's safety advisory notice.
"GE Aviation is conducting metallurgical analysis on the propeller flange and hardware at its laboratories in Cincinnati, USA. They are also inspecting additional propeller gearboxes and reminding all operators to follow maintenance and inspection procedures.
"GE Aviation will release additional maintenance and inspection recommendations if they become necessary."
(04-13-2017, 07:17 PM)Peetwo Wrote:(04-13-2017, 06:32 PM)P7_TOM Wrote: The Rex Saab and the missing propeller:-HERE.
Quote:Preliminary report published: 13 April 2017
The occurrence
On 17 March 2017, a Saab 340B aircraft, registered VH-NRX (NRX) was being operated as RXA768 on a routine passenger flight from Albury, New South Wales (NSW) to Sydney, NSW. On board the aircraft were 16 passengers and 3 crew.
About 55 nautical miles south-west of Sydney airport, the crew noticed uncommanded engine indications and began the necessary checklists. While undertaking the checklist items, the crew experienced minor vibrations from the right engine. These vibrations worsened as the checklist progressed and became visually evident to the First Officer.
As a result the crew commenced the engine shutdown procedure. During the engine shutdown procedure, the propeller separated from the aircraft. The crew made a Pan-Pan[1] call to air traffic control, and completed the engine shutdown procedure. The aircraft landed without incident at Sydney airport.
Figure 1: The aircraft, VH-NRX, at Sydney airport after the incident
Source: Grahame Hutchison
An inspection of the aircraft by the ATSB at Sydney airport identified that the propeller shaft had fractured, leading to the separation of the propeller.
On 21 March 2017, the NSW Police Aviation Support Branch (PolAir) undertook a search operation for the separated propeller. The propeller was located in an area under dense forest about 8NM south-west of Sydney airport.
Figure 2: The propeller that had separated from VH-NRX as found by PolAir about 8NM south-west of Sydney airport
Source: ATSB
The propeller was found with the flange section of propeller shaft secured to the propeller assembly and a fracture through the propeller shaft. ATSB subsequently removed the remaining propeller shaft and integral flange section (Figure 4) for examination at its facilities in Canberra.
Propeller shaft examination
The recovered part of the propeller shaft is highlighted in figure 3. The propeller was found properly secured to the forward-facing flange by bolts and the dowel pins pictured. The examination was conducted with representatives present from the Civil Aviation Safety Authority (CASA), SAAB, GE Aviation (engine manufacturer) and Regional Express (REX). Initial observations revealed cracking that appeared to run between the main shaft and the flange region. The part was sectioned in order to expose the crack’s fracture surface.
Figure 3: Propeller gearbox schematic highlighting the recovered section of the propeller shaft
Source: GE Aviation, modified by ATSB
The crack was found to be a fatigue fracture that had initiated within the propeller mounting flange, and then transitioned into the shaft section (see figure 4). The crack originated at the bore of a dowel pin near the forward face of the propeller hub flange. The dowel pin bore was corroded in parts (shown in figure 5), and corrosion pitting was found near the fracture. Further work is ongoing to ascertain whether the corrosion or other factors contributed to the fracture initiation.
Figure 4: Section of the propeller shaft showing the fatigue crack originating at the dowel hole and progressing into the shaft itself
Source: ATSB
This is the first known critical failure of this type initiating within the propeller hub flange of a GE Aviation CT7-9B engine. The same propeller gearbox (PGB) is fitted to multiple variants of the CT7 engine (5A2, 7A1, 9B, 9C, and 9C3) on SAAB 340 and EADS CASA[2] CN-235 aircraft. There is currently no maintenance requirements specified in existing maintenance manuals for routine inspection within the dowel pin bores. Any corrosion or cracking within the bore may go undetected until it progresses to the surface of the flange. Other than a visual inspection of the flange during propeller removal, inspection for surface defects (via magnetic particle inspection or dye penetrant inspection) only occurs when the PGB is disassembled for maintenance at a workshop specifically approved by the engine manufacturer.
Figure 5: Corrosion observed within the bore of the dowel pin hole
Source: ATSB
Safety advisory notice
AO-2017-032-SAN-001:
The ATSB advises that those responsible for the operation and maintenance of SAAB 340 and EADS CASA CN-235 aircraft fitted with the GE Aviation CT7 engine type variants 5A2, 7A1, 9B, 9C, and 9C3 should note the facts presented in this preliminary report with a view to addressing any risks to their own operation.
Proactive safety action taken by GE Aviation
GE Aviation is actively involved in supporting the Australian Transport Safety Bureau in this investigation. The propeller flange and all required hardware has been transported to GE Aviation laboratories in Cincinnati for further metallurgical analysis.
GE Aviation is inspecting additional PGBs from the fleet and recommends that all operators follow existing maintenance and inspection procedures. As the investigation progresses GE Aviation will release additional maintenance and inspection recommendations if they become necessary.
Proactive safety action taken by Regional Express
Regional Express has quarantined all propeller gearboxes with propeller shafts of the same series as that installed in VH-NRX.
Further investigation
The investigation is continuing and the ATSB will focus on:
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 organisation. 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 .
- maintenance procedures associated with the PGB shaft
- factors that may have contributed to the fatigue fracture at the propeller mounting flange, possibly including:
- design and manufacturing of the dowel pins, bores, and overall assembly
- corrosion protection on the surface of the part
- opportunities for crack detection.
Speedy, sane and in all probability, the right answer - stressed component corrosion?. Well done ATSB, and GE.
Quote:
Rex fractured propeller part not in maintenance program, ATSB report says
The Australian - Apr 12, 2017
The fatigue fracture that caused a Rex plane to lose a propeller over southwest Sydney last month “may go undetected” because inspections of the part are not included in the regular maintenance program, Australia's safety authority has revealed.
Quote:..Last month, The Australian reported claims by veteran pilot Byron Bailey that had the pilots not taken action to shut down the engine, the propeller would have been spinning much faster and then impacted the plane, potentially causing catastrophe. Mr Bailey is a former RAAF pilot and is now a commercial pilot who has flown more than 26,000 hours during a career spanning 45 years....Botswana O'Hooligan provides IMO a comment worthy of a QOTM nomination and a choccy frog to boot...
However, Rex deputy chairman John Sharp said Mr Bailey’s assertion was “emotive and completely unfounded”.
“Further, the propeller only separated when the first officer selected ‘fuel off’, which also feathers the propeller,” Mr Sharp said.
He added that Rex had exercised an “abundance of caution” and replaced the gear boxes and shafts of five aircraft which were of the same series as the separated propeller.
Mr Sharp also disputed the claim by Mr Bailey that the gearbox was a weak link in this type of engine and had been linked to the cause of the incident.
“The General Electric engine fitted to the Saab 340 is a free power turbine and as such, the engine and gearbox have no mechanical connection as most industry professionals would be aware,” Mr Sharp said.
The ATSB report did not find that engine overheating, caused by problems within the gearbox, were linked to the loss of the propeller, as Mr Bailey had suggested...
Quote:Botswana O'Hooligan
2 days ago
There is a law called Murphy's Law and it states that anything that can go wrong, will go wrong, particularly where aeroplanes are concerned. Elsewhere in this newspaper today it has been written that a 747 had a stick shaker activate when on descent. Stick shakers activate when the machine is about to stall aerodynamically, that is when the angle of attack of the airfoil approaches about 15 degrees to the airflow. Apparently, or so they say, this took place when they were no where near a critical angle of attack but the orange boxes containing the flight data recorder and the cockpit voice recorders will no doubt shed light on that.
GE probably thought that the prop mounting flange was there forever and there was no need for an inspection.
One night a fourteen feet in diameter prop on the machine in my care went into what the Poms call -auto coarse pitching- tho we call it -auto feather- among other things unprintable, for no reason at all, and the manufacturing people in the UK said in a hurt tone, "old chap this cannot happen," but about a month later in a different aeroplane the same thing happened again. The Poms were horribly upset for it just cannot happen they wailed.
Another night ex a joint called Midway island for Adak in the Aleuts, when passing through thirty thousand feet, bitching Betty told us that we were far too low and we should pull up immediately and initiated a pull up manoeuvre on long suffering "George," aka one of the auto-pilots. Since Everest is lower than that, Betty was having some kind of hissy fit.
All the above examples are simply demonstrating Murphy's Law and if anything can go wrong, it will, and that's why, even after being a professional pilot for fifty five years I am only scared of three things even in retirement, heights, women, and aeroplanes.
Quote:Rossair grounds all flights, confirms chief pilot among three dead in Riverland crash
Updated 54 minutes ago
Wed 31 May 2017, 11:29am
Photo: Martin Scott (left) was an experience pilot and Paul Daw was retraining at the time they both died in the plane crash. (LinkedIn/Facebook)
Map: Renmark 5341
Rossair has grounded its fleet of aircraft as a precaution in response to a plane crash that killed three people in South Australia's Riverland yesterday afternoon.
Rossair chief pilot Martin Scott, 48, and two passengers — Paul Daw, 65, who was taking an induction test, and Civil Aviation Safety Authority representative Stephen Guerin, 56, — were on board the nine-seater Cessna Conquest.
The plane was travelling between Adelaide and the Riverland.
CASA said Mr Guerin was observing a check flight conducted by Rossair as part of routine safety work.
In a statement CASA said Mr Guerin had worked with the authority since 2008 as a flying operations inspector, and at times acted as a team leader — prior to that he was a pilot for a number of aviation operators.
Quote:"Mr Guerin is remembered by CASA colleagues as passionate about aviation, meticulous about safety and widely respected," the statement said.
"He was active in community service and known as a true gentleman."
Rossair staff 'in shock'
In a statement Rossair said the crash had been a devastating blow for the families involved, the company and the group's 30 employees.
"Our staff are in deep shock at our loss and our deepest sympathies are with the family members concerned," the statement said.
"This is an extremely sad event. Rossair will work with aviation authorities to determine the cause of the crash."
Photo: All Rossair flights have been grounded since the plane crash. (ABC News: Nathan Stitt)
Charter flight service Hartwig Air's manager David Blake said Mr Daw had worked as the organisation's chief pilot and was a "larger than life" character who "lived and breathed" aviation.
Quote:"Paul exuded aviation - he was a complete enthusiast," Mr Blake said.
"Paul was a very big family man and family was very important in his life.
"He never let anybody down, he was always there for people and that is I think one of the biggest epitaphs I can offer."
Mr Blake said Mr Daw was due to retire from the organisation on Friday, but had already started making other plans to continue flying with Rossair.
Mr Blake also paid tribute to Mr Guerin saying he would be dearly missed by staff at both Bruce Hartwig Flying School and Hartwig Air.
"He was our school's and our charter division's CASA representative and well known to people here, so the loss is pretty extensive," he said.
Photo: Rossair charters flights primarily in South Australia. (ABC Radio Adelaide: Spence Denny)
The wreckage was found in scrubland about four kilometres west of Renmark Airport just after nightfall.
Major Crash investigators from Adelaide arrived at the scene last night, and an Australian Transport Safety Bureau (ATSB) team will arrive there this morning.
Australian Transport and Safety Bureau's Neville Blythe said early information suggested the plane did not explode on impact, and that was expected to be a big help for investigators.
"We do understand there hasn't been a post impact fire, which is very good from an investigation point of view," he said.
"It doesn't destroy evidence and that type of thing so we will be again taking our time to forensically go through everything in relation to the aircraft."
Investigators calling for crash witnesses
Mr Blythe said investigators from Adelaide and Canberra would arrive at the site late this morning or early afternoon.
The ATSB is also calling for any witnesses who were in the area about 4:00pm yesterday.
A local Anglican priest at Renmark, Paul Devenport, said he saw the plane flying over the east of Renmark moments before the crash.
"I couldn't see it totally but I could see it behind the trees, it was going quite low," he said.
"It was flying quite low and it had it's lights on."
Rossair primarily flies in South Australia and runs charter flights including for tourism ventures and mining companies.
The company has been running for 50 years and this is the first fatality it has ever had.
Photo: South Australian police block off a dirt road leading to the wreckage of the plane in the Riverland. (ABC News: Tom Fedorowytsch)
Quote:Collision with terrain involving Cessna 441, VH-XMJ near Renmark Airport, South Australia on 30 May 2017
Investigation number: AO-2017-057
Investigation status: Active
Summary
The ATSB is investigating a fatal aircraft accident involving a Cessna Conquest 441 aircraft, registered VH-XMJ, that occurred near Renmark Airport, South Australia on 30 May 2017.
The aircraft was reportedly conducting a training flight and collided with terrain shortly after departure from runway 25. All three occupants on board were fatally injured.
The ATSB has deployed a team of five investigators to the accident site with expertise that includes aircraft operation and maintenance.
While on site the team will be examining the site and wreckage, gathering recorded data including radio and radar, and interviewing witnesses.
The ATSB will issue a preliminary report outlining the facts of the accident within 30 days and present the findings of its investigation in the final report, due out within 12 months.
General details
Date: 31 May 2017
Investigation status: Active
Time: 16:17 CST
Investigation type: Occurrence Investigation
Location (show map): Renmark Airport
Occurrence type: Collision with terrain
State: South Australia
Occurrence category: Accident
Report status: Pending
Highest injury level: Fatal
Expected completion: May 2018
Aircraft details
Aircraft manufacturer: Cessna Aircraft Company
Aircraft model: 441
Aircraft registration: VH-XMJ
Serial number: 4410113
Type of operation: Flying Training
Damage to aircraft: Substantial
Last update 31 May 2017
(05-31-2017, 06:11 PM)kharon Wrote: Casa DICTATED ‘Blue line’ fever strikes again? I know, I know, wait for the details; but this new ‘regime’ of stupidity – V2 + 10 or a nice fat sandwich of wriggle room – all gone. When will they realise the SIM ain’t real.
10 minutes sin bin? – OK - sounds reasonable M’lud; thank you – bow – exeunt: at a good clip. .
Quote:Rossair Cessna crash stirs talk of live engine failure training
- Byron Bailey
- The Australian
- 12:00AM June 9, 2017
Having trained on jet aircraft 48 years ago, I have limited experience on non-jet aircraft, but a number of my aviation colleagues, some who have flown the Conquest, have proffered their opinion of the crash and on twin propeller aircraft engine failure training.
Engine failure training on all medium and larger jet aircraft is done in simulators. The V1 (decision speed) cut can be practised at length with no danger to the pilots. A jet aircraft simply requires the pilot to keep straight with the rudder after the engine failure, maintain level wings with aileron, and climb away at V2 (takeoff safety speed) after retracting the undercarriage. Indeed all jet aircraft are required to achieve a safe climb gradient on one engine. The pilot really just needs to put in a big boot full of rudder and attending to the engine failure can be done at a safe altitude.
Twin engine propeller-driven aircraft have additional problems. Unlike the one thrust lever on a jet engine, they have three levers per engine — fuel, propeller and power — and the engine has to be attended to immediately upon a failure.
The propeller, if not feathered quickly after an engine failure, can produce so much drag that the aircraft may be uncontrollable. One of my colleagues pointed out that if you simulate engine failure to idle instead of setting zero thrust then the drag from the propeller can be almost uncontrollable. In a real engine failure situation, aircraft such as the King Air have auto feather of the propeller, and the Conquest has negative torque sensing and after the pilot carries out immediate action successfully can then climb away in the Conquest at blue line speed (best rate of climb).
The problem I see in asymmetric training in propeller driven aircraft is that the pilot has no margin for error and needs to be almost perfect in flying technique and in performing the immediate engine shutdown drills and retracting the undercarriage. As well, these aircraft are certified to a lower performance requirement regarding climb gradient on a single engine after takeoff. The Cessna Conquest has ample power, but at lower speeds just after takeoff full power may not be able to be used if the full rudder authority is insufficient to keep straight and loss of control may result.
It does not matter how experienced a pilot may be — it does not preclude you from making a mistake. Several of my colleagues have pointed out that there have been more crashes due to practice training of engine failure on takeoff than have occurred through real engine failures on takeoff.
An airline operating the Conquest can use a King Air 200 simulator for emergency practice where the Civil Aviation Safety Authority approves it — without the risk associated with a real takeoff.
Byron Bailey is a former RAAF pilot and B777 captain, and now flies corporate jets.
Quote:...Meanwhile investigators have begun the work of removing the aircraft wreckage to Adelaide, including one of the bent propellers. Large sections of the fuselage have been removed from the scrubland by crane and loaded onto lorries.
The wreckage is being taken to a secure-building in Adelaide where investigators can look for possible defects, assess the damage and piece together how the aircraft came down.
A preliminary report by the Australian Transport Safety Bureau into the possible causes of the crash is expected back with the month.
A file picture of a Rossair Cessna.
An Australian Maritime Safety Authority spokeswoman said the aircraft sent out a distress signal shortly after taking off from the aerodrome west of Adelaide about 4:15pm.
"We became aware there might be an issue shortly after take-off when a distress signal was detected," she said.
The premier of South Australia, Jay Weatherill, said the crash was "tragic news" and paid tribute to the three men.
Read more at http://www.cornwalllive.com/probe-begins...OhuLJyo.99
Quote:Pilot dead in NSW north coast air crash amid poor weather conditionsMTF...P2
Updated yesterday at 2:13pm
[b]PHOTO:[/b] Emergency services at the scene of the crash in dense bushland near Bangalow. (ABC News: Joanne Shoebridge)
[b]MAP: [/b]Ballina 2478
A man has died after a four-seater aircraft crashed into bushland on the NSW north coast.
The 71-year-old pilot died after his Cessna Skyhawk crashed into dense bushland at Brooklet near Bangalow.
Witnesses reported seeing a grey aircraft flying very low over the Pacific Highway moments before crashing into trees around 9:00am.
[size=undefined]
©Mapbox ©OpenStreetMap Improve this map
[b]MAP:[/b] The aircraft came down at Brooklet near Bangalow, north of Ballina[/size]
The owner of the property where the plane crashed, Tracey Knowland, said she believed the pilot became disoriented in the poor weather conditions.
Quote:"I heard a tremendous whining noise, which in retrospect sounded like a kamikaze plane going down. But it only lasted a couple of seconds and then there was a huge crash sound," she said.
"[There were] very, very poor conditions in terms of visibility... low light, low cloud, it was light rain, fog.
"I imagine he became disorientated and has hit what is the highest point of our property."
'I just thought, the poor people'
Nathan Cooper was in his garden when he heard the crash.
"I heard a small plane engine go into very high revs and sounded like it was making a quick descent then it sounded like it had suddenly stopped, like it had hit the ground," he said.
Mr Cooper said it sounded horrific.
Quote:"It was pretty clear it was a plane in trouble," he said.
"It's that weird sound of a plane even if they're at a show when they do that huge dive and the engine roars, but then the very abrupt stop made it pretty obvious that it was a crash.
"I just thought, the poor people."
Combined investigation under way
Police chief inspector Nicole Bruce said it was not clear exactly what went wrong.
"At this stage the only route we have is that he was heading from Heck Field down to Ballina and I'm not sure where this is in relation to that route and why he would be over this side," she said.
"There will be a combined investigation between the Air Safety Bureau and our aviation branch."
Police said there was heavy fog at the time and debris was scattered over a large area.
Topics: death, air-and-space, ballina-2478, lismore-2480