[Kharon]

The mantra of perceived conflict of interest.

Hood – tabled a document.

“I consider that my prior appointments as Executive Manager Operations at the Civil Aviation Safety Authority, and Executive General Manager for Airservices Australia, provides me with a unique perspective in relation to transport safety matters. I am also conscious of my accountabilities in relation to managing any perceived conflict of interest in relation to any of the portfolios I previously held.”

“I have therefore, in relation to the Norfolk ditching accident, declared the potential for a perceived conflict of interest to the ATSB Commission on 8 June 2016, before I commenced as Chief Commissioner, and also to the Minister in accordance with the requirements of the Public Governance, Performance and Accountability Act 2013”.

“I have undertaken not to participate in the Commission's consideration of the investigation or the approval process for the release of this report and the ATSB's Aviation Commissioner, Chris Manning, will be the Commission spokesperson for the report”.

“Possible Perceived conflict of interest”. Must be the new version of “I was in Montreal”, it’s get a fair amount of use by professional snake oil salesmen at Estimates – must have something to do with being associated with the ‘Match fit’ mob. The words of Whostoblame adopted by his catamites; (Retch), can’t these bus stop partners dream up their own weasel words? Just so it don't sound 'too' rehearsed.

Well punters; it’s a three card draw to decide which horse Hoody will be riding in the Conflict Cup.

Errant Dobber – Gelding; by Golden Immunity out Queens Evidence.  Raced hard this season, last outing at the Estimates Stakes saw a revival of hope for the connections as a last minute dash for the tape brought the crowd to it’s feet as ED stole the race by a full head. The “Whistle-blower” stable is, once again, becoming a punters favourite. Plenty for the horse @ 5/2.

Independence Gambit – Filly; by Distance Me out of Golden promises. ‘Flighty’ is the best way to describe this maiden; and a challenge for the bookies. On form and handled correctly, the Filly has produced some stunning results – at good odds.  But any serious investment is expected to take a while to mature.  Patchy support ante post @ 4/1 but could shorten after the Pel-Air Miracle Mile .

Rectal Coverage – Gelding; by Top Cover out of Desperation Made.  A solid performer and always in, or close to the top money; and, a cornerstone of many a trifecta win. Solid credentials as a place getter, every race. The fabled, incredibly wealthy connections of this syndicated horse have and will continue to go to extreme lengths to ensure that neither they, or their friends are disappointed with a result. Wins are rightfully expected, places a certainty in nearly every event. Anything better than Evens is going to be hard to find.

There may be a challenge yet to the choice of Hood as a contestant. There is no doubt that he is well and truly qualified to ride in the Conflict Cup, none whatsoever. But, if the Stewards have done their jobs properly and identified the alleged nature of the Hood conflict and his part in what was clearly a failed attempt to fix the Pel-Air Miracle Mile; then all bets are off.

So, dear punters bet early for best odds; wagers will be refunded should there be change in the field or in the prospective riders.

Toot-toot.

[Gobbledock]

Sadly '20,000 leagues beneath the Norfolk sea', ridden by Jules Walsh and trained by M. MrDak has been scratched. Would have been interesting to watch.
However I still see 'Foley's Folly', ridden by C.Manning and trained by M.Dolan as being a potential long shot at 200 to 1.

Finally, statistics show that anything bred and trained from the stables of Hood, Dolan and MrDak are genetically flawed or mutated and not capable of eating a single carrot let alone winning the Melbourne Cup.

P.S - word of warning to the jockeys. Whoever wins the cup should abstain from
skulling out of it. The Gobbledock out of contempt for the field has already pissed in it!

[ventus45]

I don't think a bucket, even two, indeed, even a long "bucket brigade" will do, not any more.

We have long passed the point of the usefulness of buckets, in any number, for the quick catching of occasional vomits. We have entered the final leg, the terminal phase, of "continuous chundering".

Accordingly, what we need now, is a plumber, to install a special "chunder bowl", next to the computer desk, with a heavy duty suction pump, piped directly into the sewer !!

[Kharon]

Good call ‘V’. Action follows.

Positions vacant – Plumber.

Wanted – a talented, innovative plumbing professional to design, provide and install a unique “Chunder –bowl” system for the Styx river house boat park.

The client envisages a bucket shaped (traditional) Chunder Phone (CP)– connections to the annoying the gods network are not required. The colour must be ‘Burple’; that rich blend of red wine, ale, Brisbane hot dogs; or, Curry, which present, often unannounced with the uncontrolled wind gusts, which seems to emerge after a serious night ‘on the tiles’ (so to speak).  Carrot filter and disposal method an essential priority.

A CP will be required in several locations; the workshop, the study, the billiards room and the stables; with extra fittings at the BRB HQ. Best put one in the AP reading room, the researchers there often have events –at a fairly ‘high' frequency.

Transport will be provided by white elephant aviation, accommodation ‘on –site’ may be provided, should the successful tenderer have objections to off world travel and the GD (master wind breaker) has offered to assist with the wind tunnel testing.

Please contact Aunty Pru – through the usual channels, for contractual specifications.

Yuk, Yuk Yak.

[Peetwo]

AAI & the implications of bureaucratic O&O

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

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:

Near miss for planes carrying 18 people  

• by: Matthew Denholm
  
• From: The Australian
  
• September 17, 2015 12:00AM
  

Tasmania Correspondent
Hobart




Too close for comfort. Source: TheAustralian

An “unsafe” close encounter ­between two planes near Mount Hotham Airport in Victoria allegedly placed up to 18 lives at risk, fuelling demands for better use of radar at Australia’s regional airports.  

According to an incident ­report obtained by The Australian, two Beechcraft B200 King Air planes on private charters from different companies — one from Essendon in Melbourne and one from Bankstown in Sydney — were vertically within 300ft (90m) of each other on September 3.

It appeared the Essendon-based pilot, struggling with a faulty GPS in heavy morning cloud and poor weather, did not know where he was and reported being in vastly different locations, varying by up to 20 nautical miles, within a short period of time.
Radar traces of this plane, chartered from small Essendon-based operator Seidler Properties, show an apparently erratic path at times, and that the scheduled 38- minute flight took an hour and 27 minutes.

The Essendon plane came within one nautical mile (1.8km) of the other aircraft and eventually landed at Mount Hotham, in the Victorian Alps northeast of Melbourne, but only after what the report by the other pilot ­described as an “unsafe” approach from the “wrong direction”. There were three other aircraft also en route to the airport at the time.

The report, titled “breakdown of separation”, says passengers on the Essendon-based plane were so shaken they refused to return with the same pilot later that day, ­requiring another to be flown to Mount Hotham to pick them up.

In a report being investigated by the Australian Transport ­Safety Bureau, the pilot of the Bankstown-originating aircraft — a senior pilot at a major charter firm — describes the situation as “not safe”.

He suggests he is making the report not to attack the Essendon-based pilot, but rather to highlight an ongoing risk of tragedy in the absence of a safety back-up in cases of pilot error at uncontrolled regional airports.

“If this event did result in a midair collision, two aircraft would have been destroyed and 18 people would have been killed,” says the Bankstown-originating pilot in the report, sent to the ATSB two days ago.

“As a chief pilot, I am significantly concerned with the breakdown of (aircraft) separation caused by this incident. This is not a standard of operation that I would tolerate from my pilots and I do not accept that his event goes without investigation.

“Two high-performance aircraft with 300ft separation (vertic­ally), within one nautical mile of each other (horizontally), in IMC (instrument meteorological conditions), is not safe.”

The incident has further highlighted the lack of radar control of aircraft to low altitudes at ­regional airports in Australia, which The Australian has documented in the series of articles over the past two months.

In uncontrolled airspace, ­pilots must communicate with each other by radio to ensure they remain safely separated, with no support from an air traffic controller monitoring them on radar or providing co-ordination.

At Mount Hotham, radar-based separation of aircraft ends at 18,000ft, below which pilots must self-separate, despite radar being available to a far lower altit­ude.

Veteran aviator Dick Smith told The Australian the latest Mount Hotham incident highlighted the need to make full use of radar coverage at regional airports to improve safety.

“If they were using the existing radar for control at Mount Hotham, neither of these things (the ­alleged mid-air near collision and subsequent alleged dangerous ­approach) would have happened, because the controller would have told the pilot what was happening,” Mr Smith said.

He said it was particularly frustrating the existing radar was not being used to control aircraft to low altitude at Mount Hotham, given the deaths of three people in a crash there in 2005 and of six people in an accident at Benalla, about 150km from Mount Hotham, in 2004. He believed both crashes could have been averted had radar control close to ground level been provided.

“How many more frightening incidents like this before there are more unnecessary deaths?” Mr Smith said.

He said all that was needed to make use of existing radar for separation control to low altitudes at regional airports was for Airservic­es Australia to provide more training to controllers at its Melbourne and Brisbane radar centres.

Airservices insist the air traffic system is safe and that levels of control around the country are appropriate for local traffic volumes and types.

An ATSB spokesman said the latest Mount Hotham incidents were being investigated.
However, an official statement on the bureau’s website refers only to the “unstable approach” to the runway; not the earlier alleged close encounter. Seidler Properties suggested it was unaware of any investigation and declined to comment.

To think this 'serious incident' may have gone unreported 
How many other similarly serious occurrences have gone unreported (I personally know of a couple) because of fear of retribution or incriminating oneself.

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:

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:

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.

  
WTD...

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.

ATSB - who the fuck needs them...


MTF...P2

[Peetwo]

ATSB O&O investigation number...

Via the Oz today:

Skydive plane crash inquiry questions ‘loose’ pilot’s seat

• Rory Callinan
  
• The Australian
  
• 12:00AM June 5, 2017
  

A draft investigative report into one of the nation’s worst sky­diving plane crashes struggles to definitively pinpoint the cause but considers the possibility of the pilot’s seat not being ­anchored.

The aviation safety watchdog’s probe into the 2014 crash that killed a pilot, two skydive instructors and their two pupils on Queensland’s Sunshine Coast also raises questions about how skydiving business flights do not need an air operator’s certificate — a safety system required of commercial passenger, freight and charter plane operators.

Pilot Andrew Aitken, 24, tandem­ skydiving instructors Glenn Norman and Juraj Glesk, and first-time skydiving pupils ­Rahuia Hohua, 27, and Joey King, 32, died when the single-engine Cessna crashed seconds after takeoff at Caboolture Air Field on March 22, 2014.

The Aviation Transport Safety Authority has confirmed that the public report into the crash would be released within a month, with a draft report provid­ed to the parties directly involved for response. An ATSB spokesman said the agency was finalising a review of the received submissions but would not comment until it was completed.

The Australian has learned that the draft report makes reference to other crashes where the pilot seat had moved, leading to the pilot losing control.

It also notes the locking pin holding the seat had sheared off — a scenario that has been interpreted by the skydiving plane’s owner, Paul Turner, as proof that the seat-anchoring mechanism, which had only recently been replac­ed, was not to blame.

The report is believed to look at whether an instructor would have been sitting with his back against the seat, stopping movement, but it points to images from previous flights showing instru­ctors sitting elsewhere.

Fuel problems have been ruled out, while the plane’s engin­e was still operating at the time of crash and the propeller was also rejected as being at fault.

Another focus is on how skydive business flights do not need an AOC — a system of safety checks and procedures involving such things as having an approp­riately qualified “chief pilot” overseeing flying operations, pilot training and maintenance and being subject to Civil Aviation Safety Authority audits.

Commercial skydiving flights are instead governed by CASA regulations administered by the Australian Parachutists Federation. CASA delegates its ­enforcement powers to the APF, which appoints “national offic­ers’’ to be in charge of areas such as training and aviation.

The draft report examines how the plane in the Caboolture crash was damaged six months before in an incident the owner blamed on a hard landing or steep descent. The ATSB is understood to have sent pictures of the aircraft’s doors to Cessna experts, who indicated they believed the damage to the aircraft wasn’t caused by the doors flying open in flight.

Contacted yesterday, the plane’s owner said he “did not have a lot of confidence in the ­accuracy of the report”.

He said he did not wish to comment further, given the repor­t was not finalised.

APF chairman Grahame Hill said yesterday the APF rejected claims skydiving needed an AOC because the current regul­ations “mirror an AOC’’ anyway. He said he believed CASA had a similar position.

CASA declined to comment.

---

P2 - IMO the one and only comment (so far) says it all really :

Sara

Seriously - 3 years for a draft report?   What planet does the ATSB live on?

A quick perusal of the investigation page shows that the page was revisited back on 14 Feb 2017 but there has been no further update on the investigation process since 30 June last year - see HERE.

Here is the now familiar litany of excuses for the O&O of this investigation -

Updated: 30 June 2016

Quality assurance and management review of the draft investigation report is in progress prior to being forwarded to the ATSB Commission for approval for release to directly involved parties (DIP).

The draft investigation report is now anticipated for release to DIPs for comment on the factual accuracy of the report in July 2016. Feedback from those parties over the 28-day DIP period will be considered for inclusion in the final report, which is anticipated to be released to the public in September 2016.



Updated: 1 March 2016

The additional investigative work reported in our 19 October 2015 update has been completed. Quality assurance of the investigation and draft report is being finalised before ATSB Commission approval of the report for release to directly involved parties (DIP).

The draft investigation report is now anticipated for release to DIPs for comment by mid‑April 2016. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in June 2016.



Updated: 19 October 2015


Completion of the draft investigation report has been delayed to allow for additional investigative work and by competing team member priorities and workload. It is now anticipated for release to directly involved parties (DIP) for comment in December 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in February 2016.



Updated: 25 August 2015

Completion of the draft investigation report has been delayed by competing priorities and workload, and is now anticipated for release to directly involved parties (DIP) for comment in October 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in December 2015.



Update: 14 May 2015

Completion of the draft report has been delayed by team member competing priorities on other investigations and is now anticipated for release to directly involved parties (DIP’s) for comment by the end of June 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated for release to the public in August 2015.

Beaker MKI/Beaker MKII (Hoody) were probably too busy providing top-cover expertise for the Malaysians and for the nearly 8 year (re-)investigation saga of the PelAir cover-up...


MTF...P2

[Gobbledock]

Once again, what a joke. 3 years to get the report to 'draft' stage. Too bad if there are risks out there of reoccurrence due to a design flaw or something similar.

Hoody the hi-vis homo is continuing Beakers legacy of not investigating accidents in a timely manner. What fools.

[Kharon]

Seems like the grown up’s have finally woken up to see the mess left in the kitchen. Interesting article  – Tweeted by V45.

[Peetwo]

Aussie O&O of the ICAO ADREP system: cont/-

To perhaps help provide a running form guide for the potential entrants to the BRB sponsored ICAO Obfuscation Cup, I will continue to publicly reveal my discoveries as I troll through the records of Australian (non-)conformity with occurrence reporting to the ICAO ADREP system.

Reference: BRB BT: The IR mole & the ADREP cock-up(rort)?

ACTION TAKEN BY THE ATSB:


The use of ECCAIRS was considered as an option for the occurrence database module of the ATSB's newly developed Safety Investigation Information Management System. Given that most of the aviation data collected by the ATSB is high-volume, low-detail data, the complexity of the ECCAIRS taxonomy was not considered appropriate. A bespoke taxonomy for safety events and safety factors was developed by the ATSB which better suits its needs, particularly for the purposes of safety research and for the application of its investigation safety analysis methodology. However, a mapping exercise was carried out to ensure that there was comparability between the ATSB and ECCAIRS taxonomies. For the purposes of notification, preliminary and final ADREP data reports, the ATSB continues to provide this information in the ECCAIRS format, including the use of the ECCAIRS taxonomies. 

Reference: 2004 ICAO ATSB - Audit Report [ Download PDF: 2.86MB]

Okay so from the above it can be seen, that even as far back as 2004, the ATSB had some serious deficiencies in forwarding safety issue information, occurrence notifications and preliminary/final reports to be inputted into the ICAO ADREP (iSTAR and ECCAIRS databases). So for other than the original occurrence notification, the ATSB solution (ref: Appendix 5-1) was not to try and match the ECCAIRS taxonomy but for everything (data/prelim/final reports) to be forwarded to the ICAO ADREP Secretariat in a copied PDF format.

On a read of the minutes of the 2008 ICAO IAG divisional meeting it was discovered that the taxonomy issue with the ECCAIRS IT application, was a common problem with some individual States. The IAG recommended a proactive action plan to tackle this. 

Based on the 2008 ICAO audit report on Australia (the audit occurred before the IAG meeting), it would appear that the issue had been effectively addressed by Australia.

The problem was also lessened for Australia by the introduction of notified differences to ICAO Annex 13. In particular the ATSB exempted itself from forwarding all preliminary reports for discontinued/not to be investigated occurrences.

There was also a ND for the requirement to investigate the accidents/serious incidents that would normally be required under Annex 13.

This was discovered in the course of the 2008 ICAO audit, with the finding leading to the issuing of an audit recommendation:

  
Remembering that the IR data input mole was in charge of the forwarding of data to ADREP from 2001 until sometime in 2012. This was when EH became the REPCON manager and presumably the ATSB ICAO coordinator.

I then fast forward to November 2015 with the discovery that EH had modified a PDF copy of the VH-NGA prelim report (created 15/01/2010). However tracking the changes to this document finds no changes. I could be wrong but IMO signifies that this document was on file at the ATSB and was simply forwarded by EH to ADREP on the 10/11/2015. 
 
This then got me thinking that maybe there were other similar aberrations...
This led me to reviewing all PDF copied prelim/final reports from 2009 till 2015. What I discovered was that nearly every report from occurrences between 2009 till 2011 was inputted by an ATSB Officer in the course of a week before and after EH modified the VH-NGA PDF copied prelim report.

I also discovered that there are still a significant number of serious incident/accident reports that have to this day not been submitted to ICAO and are not listed on either the ECCAIRS or ICAO iSTAR databases. One of these occurrences just so happens to be an occurrence that had the real potential to be Australia's worst aviation accident disaster - i.e. the Mildura Fog landing...

TICK..TOCK 6D, Malcolm in the middle & Barmybaby, TICK..TOCK indeed!

MTF? Definitely...P2

[Peetwo]

Has the worm turned on 'organisational factors' and O&O'd investigations?

Off search 4 IP yesterday : Update: ATSB PC accident investigation AO-2014-032

Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 

• Tab - Summary
  

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
• reviewing other investigations and references where similar themes have been explored.
  

Then yesterday as reported by WA Today (note my bolding):

October 25 2017 - 12:12PM

Perth Skyshow plane crash: ATSB probes other airshow disasters, safety standards

• [/url]David Allan-Petale
  [url=http://www.watoday.com.au/wa-news/by/David-Allan-Petale-gxi4aw]
  

The investigation into what caused a fatal plane crash on Australia Day in Perth has analysed other disasters including the 2015 Shoreham Airshow crash in the UK that killed 11 people.

Perth pilot Peter Lynch and his passenger and partner Endah Cakrawati died when the Grumman G-73 amphibious aircraft crashed into the Swan River during the City of Perth's annual Skyworks event on Australia Day.
 


The Grumman sea plane crashed into the Swan River on Australia Day, killing its two occupants. Photo: Mike Graham
 
The seaplane nose-dived into the water about 5pm in a plunge the Australian Transport Safety Bureau said was "consistent with an aerodynamic stall".

The plane broke on impact in front of hundreds of horrified witnesses gathered along the Swan River foreshore to watch an air display Mr Lynch was part of in the lead up to the fireworks show.
 
In a statement to WAtoday, the Civil Aviation Safety Authority said Mr Lynch's aircraft was operating as part of an approved air display, which was given special permission to operate.

Immediately after the crash, the ATSB began an investigation and is now probing the "planning, approval and oversight of the air display", sifting through years of data for the Perth event and other air displays across Australia, as well as "procedures and guidance relating to Civil Aviation Safety Authority (CASA)‑authorised air displays".

As part of its inquiry, the ATSB analysed the Shoreham Airshow crash, in which an ex-military Hawker Hunter jet aircraft failed to complete a loop manouevre and crashed into a highway, killing 11 people on the ground and injuring 13, including the pilot.

The final report of a UK investigation into that crash concluded it was caused by pilot error, with the aircraft too low to safely complete the loop.

The Shoreham Airshow crash killed 11 people on the ground. Photo: Nicholas Hair via Twitter @NDH37087  

For the Perth crash, the ATSB had previously said it had "not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water".

However, it looked at the Shoreham crash to compare the approval processes and safety regulations for airshows around the world with Australia.


An ATSB image showing the flight path of the plane over the foreshore and river. Photo: ATSB
 
"Preliminary analysis of this information has identified differences in the approval process within CASA, between civil and military (including combined) displays and between Australia and other countries," the ATSB said.

"The ATSB is continuing to analyse this information, to determine whether there are any systemic safety issues in relation to authorised air displays."

The investigation is continuing, with a final report expected to be completed by January 2018.

Maybe wishful thinking but I am beginning to get the impression that someone has read Hoody and the ATSB the riot act on PC'ing and obfuscating systemic regulatory oversight issues in AAI - 

MTF...P2

[Peetwo]

ATSB O&O Investigation number: AO-2014-043

So after 1352 days we end up with a ATSB investigation that is summarised like this:

What happened
On 3 March 2014, the flight crew of a Tiger Airways Australia Pty Ltd (Tigerair) Airbus A320 were preparing for a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia. The flight crew had earlier completed uneventful sectors from Sydney to the Gold Coast, Queensland, and return. As part of that preparation, the flight crew reviewed the operational flight plan (OFP) for the sector. The OFP was produced by the operator’s Operations Control Centre. That OFP contained significant errors in the aircraft weights, and as a consequence the required fuel upload for the sector was also significantly in error. The aircraft captain chose to re-calculate the required fuel load using resources available on the flight deck. The resultant required fuel load calculated and uplifted by the captain did not include the operator's requirement to carry a '60 minute top-up' additional fuel, resulting in the fuel upload being below that required under the operator's operations manual. The aircraft’s flight computers, however, identified that the aircraft would arrive at its destination with more than the minimum inflight fuel requirements. During the subsequent flight, the flight crew regularly checked the fuel usage and expected arrival fuel at Perth. All company and regulatory inflight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves.

What the ATSB found
There were deficiencies within the processes and procedures used by the operator's Operations Control Centre that permitted incorrect plans to be produced and subsequently provided to flight crew. This increased the risk that, in the time pressured environment of pre-flight planning, flight crews could either overlook incorrect data and accept an incorrect flight plan, or err in the calculation of the required fuel upload. Further, the operator provided limited guidance and assistance for flight crews on the processes and procedures for correcting identified fuel planning errors. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, resulted in the decision to determine a correct required fuel load calculation using only those resources available on the flight deck. Due to the short layover between sectors, which was further aggravated by curfew restrictions, this increased the risk of critical fuel planning considerations being overlooked.

Safety message
A correctly calculated flight plan not only provides assurance to both the captain and the operator that all operational factors likely to influence the flight have been considered and accounted for, it also forms an important inflight validation tool to allow crews to monitor and continually assess those decisions made at the pre-flight stage. Where variances are noted, timely alternative plans can be implemented to ensure that aircraft arrive at either the destination or an alternate aerodrome with required fuel reserves preserved.

However if you continue to read down the page you will eventually get to the 'nuts & bolts' section of the final report i.e. the safety analysis/conclusions/safety issues.

 'Safety analysis' (note part in bold):

Tiger Airways Australia Pty Ltd used an Operations Control Centre (OCC) to provided flight planning support for the flight crew of their regular public transport flights. Operations controllers (OC) were responsible for the production of flight planning and supporting documentation, which included generating the operational flight plan (OFP) and associated air traffic services flight plan.

There are various reasons for using an OCC for flight planning, including cost and duty time considerations. The use of an OCC system to produce flight planning products enables operators to reduce the flight crew’s flight planning task from gathering information and developing the flight plan, to one of reviewing prepared documentation and a finalised OFP. This has enabled operators to significantly reduce the time spent by flight crew in the flight preparation phase. Under regulation and the operator’s own policy and procedures, however, the aircraft captain was responsible for the proper planning and conduct of a flight.

The production of a correct OFP is essential for the safe completion of a flight. It ensures, amongst other things, that:

• the calculated fuel upload contains all required components
  
• the fuel upload is sufficient for the required flight given the conditions expected for that flight
  
• there is an accurate method of tracking inflight fuel usage
  
• the aircraft will arrive at the destination with sufficient fuel to ensure a safe landing.
  

   
Does this indicate that despite 'just culture' and the fact that the aircraft under 'Other Findings' met...

"...All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves..."

...that the Captain may have been scapegoated in order to allow time for the ATSB to again O&O an investigation (to the benefit of the operator) but at the detriment of the real glossed over safety issues i.e. safety risks associated with quick turn-around & LCC operations. 
 

MTF...P2

[thorn bird]

"...that the Captain may have been scapegoated in order to allow time for the ATSB to again O&O an investigation (to the benefit of the operator) but at the detriment of the real glossed over safety issues i.e. safety risks associated with quick turn-around & LCC operations. "

So what is the "Issue"?

The crew picked up the "error", mitigated it, and successfully completed the mission.

"...All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves..."

Still don't get it, but one could draw parallels to the Pelair debacle. Crew undertook the flight and broke no rules, yet still get mentioned in dispatches implying they had done something dodgy. In the Pelair case the pilot is still paying the price for having the temerity to point out that it wasn't just him. There were other severe deficiencies within the processes used by the operator, as well as the provision of timely weather information and regulatory oversight. That was completely ignored by the ATSB, pushed aside to focus blame entirely on the pilot.

[Kharon]

Of delay and denial.

"Mistakes are not always the result of someone's ineptitude."

The report above intrigues me: 1352 days invested in a report which changes nothing. Why bother. Quick turn around and ‘on time performance’ are management and PR tools, nothing whatsoever to do with ‘aircrew’ duties and responsibilities. Now if the air crew are too worried about ‘pressure’ there is a union to complain to: but, and most importantly, there is a Safety Management System (SMS), which is legally binding and fully auditable.

A report in the SMS system demands attention; an incident, like the one mentioned above should have an open ‘action’ trail, in which the response from ‘management’ may be clearly seen and the ‘remedy’ examined.

An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place. The company SMS in a perfect world would have identified, much more quickly than the ATSB where the problem lay and been able to quickly effect a solution – which the ATSB have failed (again) to provide. The company can, in a heartbeat, issue ‘orders’ to change an anomaly in their system; ATSB cannot. So why even involve the ATSB in any way except as an ‘auditor’ of the SMS?

Tiger SMS team are obliged, by law, to investigate – there would be a paper trail. All ATSB need to do is send in a couple of auditors to check that all has been attended to – correctly and that should be the end of the story. We either trust and use the SMS; or, save the company the cost.  This double up, where there are no effective cross checks or balances is ridiculous. Why not let Tiger sort out the problem, audit their response and ‘order’ any changes ATSB deemed necessary. Would save some time and money; we’d probably even get an accurate, valuable ‘report’ back in 13 days, not 1300.

The way the ATSB present this latest load of Tommy-Rot suggest that the aircrew need to back to planning their own fuel burns – for indeed they are ultimately responsible. But the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure.

[we] are not ill provided but use what we have wastefully.”

Toot toot.

[Peetwo]

Of delay and denial.

"Mistakes are not always the result of someone's ineptitude."

The report above intrigues me: 1352 days invested in a report which changes nothing. Why bother. Quick turn around and ‘on time performance’ are management and PR tools, nothing whatsoever to do with ‘aircrew’ duties and responsibilities. Now if the air crew are too worried about ‘pressure’ there is a union to complain to: but, and most importantly, there is a Safety Management System (SMS), which is legally binding and fully auditable.

A report in the SMS system demands attention; an incident, like the one mentioned above should have an open ‘action’ trail, in which the response from ‘management’ may be clearly seen and the ‘remedy’ examined.

An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place. The company SMS in a perfect world would have identified, much more quickly than the ATSB where the problem lay and been able to quickly effect a solution – which the ATSB have failed (again) to provide. The company can, in a heartbeat, issue ‘orders’ to change an anomaly in their system; ATSB cannot. So why even involve the ATSB in any way except as an ‘auditor’ of the SMS?

Tiger SMS team are obliged, by law, to investigate – there would be a paper trail. All ATSB need to do is send in a couple of auditors to check that all has been attended to – correctly and that should be the end of the story. We either trust and use the SMS; or, save the company the cost.  This double up, where there are no effective cross checks or balances is ridiculous. Why not let Tiger sort out the problem, audit their response and ‘order’ any changes ATSB deemed necessary. Would save some time and money; we’d probably even get an accurate, valuable ‘report’ back in 13 days, not 1300.

The way the ATSB present this latest load of Tommy-Rot suggest that the aircrew need to back to planning their own fuel burns – for indeed they are ultimately responsible. But the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure.

[we] are not ill provided but use what we have wastefully.”

Toot toot.

Excellent post "K"...

I to am bemused by this report and still trying to fathom why this particular incident was investigated at all. Especially when you consider that the ATSB has chosen to discontinue many other on par investigations, stating lack of available resources and/or higher priority (i.e. serious incident) investigations as reasons for discontinuing...

Q/ So why did this particular non-event, & supposedly proactively addressed by airline occurrence, require the ATSB to instigate a topcover O&O investigation?

 P9 - "..An outfit like Tiger would have a SMS – probably a good one; they would have the required personnel, system, checks, balances and decision makers in place..."

Maybe "K" that it is where the problem lies? Could it be that at that particular time the Tiger SMS was simply a tick-a-box routine that on paper met the CASA regulatory and oversight requirements but in actual fact was ineffectual in identifying and mitigating serious safety issues?

After all it wouldn't be the first time that an AOC holder, operating under a CASA approved SMS, was found to be operating with significant safety deficiencies that the SMS failed to identify and/or effectively risk mitigate.

"..the amazing thing is Tiger get thumped for ‘systematic’ deficiencies – yet the Pel-Air system of abomination only gets a passing stroke with a wet lettuce leaf. Go figure..."

Yes the classic example of a failed 'in operation' SMS is of course PelAir.

The following is an extract from former CASA Manager of Human Factors Ben Cook's Special Audit report of PelAir's FRMS (reference: CASA Special Audit of Pel-Air Fatigue Risk Management System, received 10 October 2012; (PDF 5428KB) ):

 
Note that Ben Cook highlights that the 'special audit' was a 'systemic investigation' and that he took steps to de-identify company personnel in order to not jeopardise the Rex position on positively fostering a 'just' internal safety culture.

When you consider the ongoing embuggerance of DJ it is kind of ironic that a former CASA officer was taking such steps to protect the fundamental concepts of a 'just culture' that is integral to the effective operation of a company SMS (i.e. you don't have 'just culture', you don't have an SMS).

Reference search 4 IP post: Update: ATSB PC accident investigation AO-2014-032

Then about a week ago the following new investigation was initiated (note new investigation No.) that was bizarrely co-joined to the ongoing ATR broken tail investigation -

Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 

• Tab - Summary
  

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
• reviewing other investigations and references where similar themes have been explored.
  

So maybe the ATSB investigators and HF experts on the coalface have come to realise there are some serious deficiencies in the CASA regulated and oversighted SMS of some of our major operators and SSP defined service providers (e.g Airservices, BOM) -

Naturally it would then follow that Hoody and his fellow commissioners, in the interest of political correctness and not embarrassing the minister, have developed an O&O campaign to allow the commercially and/or politically sensitive DIPs time to get their shit together and shred the negative evidence of SMS/SSP complacency - Just surmising...   


MTF? Definitely...P2

[Kharon]

Yes: But….

Well caught P2; the ’rub’ clearly defined; however we are only scratching at the high gloss paint covering. Making effective use of the SMS requires all parties – ATSB included to contribute. The ‘law’ supporting SMS is ‘robust’ and drags top level management into the spotlight and ensures that ultimate ‘responsibility’ cannot be delegated. At the end of the session, the ‘buck’ has a place to stop.

One of the little problems ATSB have is that their ‘recommendations’ have no legal bind on company management. A small shift in ‘thinking’ could remedy that. An ATSB recommendation to the company SMS system would need to be acknowledged and considered through the SMS. Say ATSB recommended that pilots wear Pink socks on Tuesday and Blue on Friday. This is fed into the grass roots level of the SMS; the system is then triggered. This is a legitimate call by the government safety agency and cannot be denied entry. So the ATSB recommendation is duly considered; dealt with and the system decides it’s a crock. This is fine, but should the next incident involve pink socks, not blue, then there is a paper trail leading right to the top mans door. If a middle level decision to deny the recommendation was made it matters not – at the end of the shift the responsibility lays with the top dog. That is how a SMS is structured.

If the aircrew don’t file a report into the system, then little can be done – unless someone else spots the deviance or the deficiency; but once that report is in ‘the system’ it must go through process, before being binned (by who and why) That ‘binning’ is now part of the system and may be called up as part of an investigation into why an event has occurred; part of a causal chain, if you will. All fully auditable, clear lines of responsibility and nowhere to hide.

A healthy company would embrace the SMS, make it real, make it live, make it useful; it is a very sound notion. Tiger have used theirs, responsibly; and, made the requisite changes. Of course the incident will happen again; there are always ‘little’ problems like the one mentioned, particularly with ‘paper-work’. The trick is to reduce the reoccurrence ratio in a demonstrable, systematic, quantifiable way.

“In 2015 we had 24 reported instances of paper-work bungles; in 2016 we had 8, in 2017 we had 3”.

Bravo, big cheer all around – the SMS at work and doing it’s job. What could be wrong with that?

Toot toot.

[Peetwo]

ATSB O&O investigation No. - AO-2015-131

Via 'that man' in the Oz today:

Anger at chopper crash probe delay

12:00amEAN HIGGINS

It has now been two years since Richard and Carolyn Green and John Davis died when the helicopter they were in crashed.

Delays to chopper crash inquiry ‘ridiculous’: Felicity Davis

Felicity Davis says while many other people have complicated marital histories, hers was simple: she married documentary maker John Davis and had two children with him. “We stuck together for 43 years,” she said.

That marriage ended two years ago when, in early November 2015, her husband died when a helicopter piloted by his friend, landscape photographer Richard Green, crashed in rugged country in the NSW Hunter Valley region during a storm. Green’s wife, Carolyn, also died in the crash, and the tragedy of the prominent Sydney environmentalist trio made huge headlines.

Ms Davis has done her best to put her life back together after losing her husband but is still tortured by not knowing how the accident happened.

That’s because the Australian Transport Safety Bureau, which initially told her it would finalise its investigation in less than a year, still hasn’t done so two years on.

“I just feel we are getting fob­bed off,” Ms Davis told The Australian. “The other day, I came back and I just thought, this is getting ridiculous.” Ms Davis has found her treatment by the ATSB disrespectful and undignified.

“I have just been waiting and waiting,” she said. “They keep saying they are going to file a report.”

There is still mystery about how the accident happened.

A farmer reported seeing the Airbus Eurocopter EC 135 land in a field at one stage, Ms Davis said, but it returned to the air. “What I want to know is, why did they set off again?” Ms Davis said.

But apart from her obvious personal interest, Ms Davis says she wants the investigation to achieve what the taxpayer-funded ATSB is supposed to do in the first place: work out what happened for the good of aviation safety.

“Was it something that the pilot did wrong, or the helicopter? We need to know because it would stop other people doing the same thing,” she said. “It’s a safety issue.”

It is exactly what an ATSB ­investigator said in a corporate video the bureau made to explain the investigation process.

“The whole idea is that perhaps we can prevent another accident happening,” the investigator said in the video.

The log on the ATSB website about the helicopter crash investigation shows repeated failure to meet its own deadlines. In October last year it said a draft report would be issued in November that year, and a final report a month later.

The ATSB then kept pushing back the date, citing “workload and competing priorities”, and now says it expects completion in “the first quarter of 2018”, which would be 2½ years since the ­accident.

An ATSB spokesman refused to answer questions about the helicopter crash investigation “until the final report into the accident is released”.

Transport Minister Darren Chester declined to comment.

 

MTF...P2  

[Peetwo]

Update to O&O investigations & the secretive ATCB -

ATSB O&O investigation No. - AO-2015-131

Via 'that man' in the Oz today:

Anger at chopper crash probe delay

12:00amEAN HIGGINS

It has now been two years since Richard and Carolyn Green and John Davis died when the helicopter they were in crashed.

Delays to chopper crash inquiry ‘ridiculous’: Felicity Davis

Felicity Davis says while many other people have complicated marital histories, hers was simple: she married documentary maker John Davis and had two children with him. “We stuck together for 43 years,” she said.

That marriage ended two years ago when, in early November 2015, her husband died when a helicopter piloted by his friend, landscape photographer Richard Green, crashed in rugged country in the NSW Hunter Valley region during a storm. Green’s wife, Carolyn, also died in the crash, and the tragedy of the prominent Sydney environmentalist trio made huge headlines.

Ms Davis has done her best to put her life back together after losing her husband but is still tortured by not knowing how the accident happened.

That’s because the Australian Transport Safety Bureau, which initially told her it would finalise its investigation in less than a year, still hasn’t done so two years on.

“I just feel we are getting fob­bed off,” Ms Davis told The Australian. “The other day, I came back and I just thought, this is getting ridiculous.” Ms Davis has found her treatment by the ATSB disrespectful and undignified.

“I have just been waiting and waiting,” she said. “They keep saying they are going to file a report.”

There is still mystery about how the accident happened.

A farmer reported seeing the Airbus Eurocopter EC 135 land in a field at one stage, Ms Davis said, but it returned to the air. “What I want to know is, why did they set off again?” Ms Davis said.

But apart from her obvious personal interest, Ms Davis says she wants the investigation to achieve what the taxpayer-funded ATSB is supposed to do in the first place: work out what happened for the good of aviation safety.

“Was it something that the pilot did wrong, or the helicopter? We need to know because it would stop other people doing the same thing,” she said. “It’s a safety issue.”

It is exactly what an ATSB ­investigator said in a corporate video the bureau made to explain the investigation process.

“The whole idea is that perhaps we can prevent another accident happening,” the investigator said in the video.

The log on the ATSB website about the helicopter crash investigation shows repeated failure to meet its own deadlines. In October last year it said a draft report would be issued in November that year, and a final report a month later.

The ATSB then kept pushing back the date, citing “workload and competing priorities”, and now says it expects completion in “the first quarter of 2018”, which would be 2½ years since the ­accident.

An ATSB spokesman refused to answer questions about the helicopter crash investigation “until the final report into the accident is released”.

Transport Minister Darren Chester declined to comment.

 

Via the Courier Mail:

Shameful heel-dragging on air incident probes

Mike O’Connor

December 1, 2017 12:00am



AS tens of thousands of Australians prepare to head to the airport for the great Christmas holiday migration, they might care to ponder the following.

In the skies over the Gold Coast on July 21 last year, an arriving Jetstar A320 and a departing AirAsia X A330, with a combined seating capacity of 520 passengers, came frighteningly close to flying into each other.

The Australian Transport Safety Bureau says the jets came as close as 183m vertically and 630m laterally when regulations stipulate the separation should be 305m and 6km respectively.

The ATSB said the results of its investigation into this would be made public in July this year. This has not happened.

According to the ATSB website, completion of the draft investigation report into the incident “has been delayed by the involvement of the investigator in charge on other aviation safety investigations and tasks”. It says a final report is anticipated to be released to the public in May 2018, almost two years after the event.

In February this year, four American tourists and their pilot were killed when their aircraft crashed soon after takeoff from Melbourne’s Essendon Airport.

It was later revealed that the pilot was being investigated over a near collision at Mount Hotham on September 3, 2015.

Essendon DFO shopping centre in Melbourne following the crash of a light plane. (Pic: Jason Edwards)

The completion of this investigation has been delayed three times due to competing priorities and workload of the investigator in charge.

In July it was promised by October. It still has not been released.

According to the ATSB, “the draft report has been finalised and is currently undergoing an internal review process prior to approval by the ATSB Commission”.

It begs the question that if the investigation had been carried more quickly, would that pilot have been at the controls at Essendon and would the Americans still be alive?

Just over two years ago, three people died in a helicopter crash in the Hunter Valley region of New South Wales.

Among the victims was pilot Richard Green, who had a history of close calls.

He had lost his licence for six months in 2013 after being involved in four dangerous flying incidents in 11 days in May 2012.
Six months later he was in trouble again when his helicopter struck power lines.

Following the Hunter Valley tragedy, the ATSB said it would complete its investigation in a year. Two years on, Felicity Davis, whose husband John died in the crash, is still waiting for the report.

Only a third of ATSB investigations are completed within 12 months.

Dick Smith has called the ATSB “secretive” and “insecure”. (Pic: Dylan Coker)


Dick Smith, a former chairman of the Civil Aviation Safety Authority, has described the ATSB as “secretive, insecure, and inclined to protect its own interests and those of companies and government instrumentalities rather than serving the public and individuals”.

“They are basically a secret, secret organisation,” he said this week.
It is screamingly obvious that there needs to be a public inquiry into the workings of the ATSB.

Business as usual, with inquiries into incidents that involve the safety of passengers dragging on for two years, is no longer acceptable.

The aim, surely, is to discover the reason for accidents or “near misses” as quickly as possible and prevent them happening again.

The system appears to be broken. The public deserves a better deal.

TICK TOCK Hoody


MTF...P2

[Peetwo]

ATCB O&O investigation No: AO-2015-007

Boy oh boy the ATCB are good at keeping these types of serious incidents under wraps - FDS...1071 days or 2yrs 11 months & 6 days for this...

What happened
On the morning of 9 January 2015, a Regional Express operated SAAB 340B aircraft, registered VH-OLM struck a flock of birds during its landing roll at Moruya, New South Wales. Inspection of the aircraft by the flight crew found bird impact marks but no visually identifiable damage. The crew continued their schedule to Merimbula, New South Wales. At Merimbula, the first officer noticed the tip of one propeller blade was missing, and the aircraft was subsequently grounded.

What the ATSB found
The blade tip failure was almost certainly a result of the birdstrike during the landing roll of the previous flight, weakening the internal structure of the blade.

The flight crew conducted a visual inspection in accordance with the operator’s procedures, and this inspection did not find any damage. However, the propeller manufacturer’s birdstrike inspection procedure was deemed a maintenance task. As such, it was not suitable for flight crew.

What's been done as a result
The operator changed its birdstrike procedures to ensure aircraft remained on the ground until a maintenance inspection was carried out in accordance with appropriate documented inspection procedures. In addition, pilot and engineering notices were issued clarifying these requirements.

Safety message
Adherence to regulations and company procedures is essential for the ongoing airworthiness of aircraft. Therefore, it is vital that procedures are clear and do not lead to ambiguity or misinterpretation. Where uncertainty exists, seeking clarification from the relevant authority can reduce the risk of an unserviceability affecting flight safety.

From FlightGlobal:

Birdstrike caused Rex Saab 340 propeller tip failure

• 14 December, 2017
  
• SOURCE: Flight Dashboard
  
• BY: Ellis Taylor
  
• Perth
  

Regional Express has changed its maintenance procedures following a propeller failure incident on one of its Saab 340s that was caused by an earlier birdstrike.

The aircraft, registered VH-OLM, struck a flock of galahs during its landing roll at Moruya, the Australian Transport Safety Bureau (ATSB) states in its final report on the incident.
In accordance with Rex’s procedures, the crew carried out a test of the ice protection system before the engines were shut down, and no anomalies were detected. During the turnaround, the pilots conducted a visual inspection of the aircraft which showed signs of a bridstrike. However, there was no evidence that birds had been ingested into the engines, nor was any apparent physical damage.

“The examination included rotating the propellers so that the forward and aft blade surfaces could be inspected for cracking, buckling, chips, dents or deformation along each affected blade’s leading edge,” says the ATSB. “When no damage was identified, the captain contacted the operator for further technical advice and the crew were subsequently cleared to continue with the flight schedule.”

After completing the subsequent flight to Merimbula, the first officer noticed that the tip of one of the left-hand propeller blades had detached, and the aircraft was subsequently grounded.

Image Source: Regional Express via ATSB

There were no injuries reported to passengers and crew, and no other damage to the aircraft was found.

The ATSB says that that impact from “multiple galahs almost certainly reduced the structural integrity of a propeller blade, resulting in the separation of its tip during the subsequent flight”.
It also looked closely at the inspection procedures for suspected birdstrikes. In their inspection, the flight crew focused on seeking visible damage to the propeller blade, and liaised with Rex’s engineering crew. However, no on-site engineering inspection of the propeller was made.

“Regardless of the nature of the flight crew’s inspection, both [the Civil Aviation Safety Authority] and the propeller manufacturer considered the inspection to be a maintenance task, and required it to be carried out by qualified maintenance personnel,” says the Bureau.

Subsequently, Rex changed its procedures to require an engineering inspection before an aircraft departs if there are signs that wildlife may have struck the propellers.

"..Adherence to regulations and company procedures is essential for the ongoing airworthiness of aircraft..." -  Is this why, for what would appear to be a relatively straightforward investigation, the ATCB saw the need to O&O this final report?

Oh well at least Hoody can say he kept it under 3 years -

Speaking of 'serious incidents' that have been O&O'd with the standard excuse of lack of resources, apparently the following 'serious incident' had the additional incentive of covering the embarrassing inclusion of a certain Turnbull Government VIP - or so the story goes...

10/11/2017

201705227


Serious Incident

West Sale Aerodrome


38° 5.502' S


146° 57.918' E


VIC

Cessna Aircraft Company

337

Charter


Passenger


CTAF

G

During approach, the crew did not extend the landing gear resulting in a wheels-up landing. The aircraft sustained minor damage.

Copy of ATSBSearchResults.xlsx Size: 125.43 KB  Downloads: 5

      

MTF...P2


Ps.

Plane carrying federal transport minister in serious safety scare

A plane carrying the federal transport minister has been involved in a serious safety scare.

[P7_TOM]

Naughty P2 – well, naughty if you are hinting that the Chester derriere suffered gravel rash or ‘bitumen burn’. That would be quite a way to ‘man-scape’ the furry parts into a new style. Probably why it wasn’t widely reported. Lucky there was a thick layer of spilled Cheezels on the floor – foam is foam; no matter how it gets there.

I wonder why a simple ‘forgot to put ‘em down’ has been kept so bloody quiet? Apart from the furry modifications – probably all to do with ‘furmolising’ his acquaintance with what, exactly, a runway is. Butt. No es problemo – the hair stylist is on the fifth floor of the large building, 30 meters to the left of ‘incident’ runway centreline, not even a long walk for a mug, two minutes by ministerial transport. Is he going to put the before and after pix on Twitter? Hope so – Oh, I can’t hardly wait to see the before and afters.

[Peetwo]

  
Update - O&O investigation No: AO-2015-007

Reviewing the ATSB webpage for this O&O investigation and final report there are some bizarre omissions to what should normally be on the public record...  

From investigation webpage: 

Birdstrike involving SAAB 340B, VH-OLM, Moruya Airport, NSW, on 9 January 2015
 
Investigation number: AO-2015-007
Investigation status: Completed
 

• Tab - Final Report
  

Final Report
Download final report
[ Download PDF: 2.08MB] 

---

General details

Date: 09 January 2015
 
Investigation status: Completed  

Time: 10:50 ESuT  

Investigation type: Occurrence Investigation  

Location   (show map): Moruya Airport
 
Occurrence type: Birdstrike  

State: New South Wales  

Occurrence class: Operational  

Release date: 14 December 2017

Occurrence category: Serious Incident  

Report status: Final

Highest injury level: None  

---

Original ATSB occurrence report record:

SAAB Birdstrike Moruya.xlsx Size: 117.89 KB  Downloads: 0

During the landing at Moruya, the aircraft struck multiple galahs. The crew conducted an inspection and the aircraft subsequently departed for Merimbula. On descent into Merimbula, the crew detected abnormal vibrations through the flight controls. After landing it was determined that a section of propeller was missing. The investigation is continuing.

From the above we can establish that the occurrence was reported properly by REX and/or the flightcrew. However there is no record of a preliminary report being published; there is no record of interim reports/summaries being published on the anniversary of the occurrence; in fact besides the FR there is no update record for the entire 1071 days that this investigation was supposedly active -

Now compare that to a ATSB investigation that took a similar amount of time to complete - AO-2013-100 (i.e. The Mildura Fog duck-up); or the ongoing Essendon DFO accident investigation: AO-2017-024.

Kind of makes you wonder if perhaps the ATSB are only properly adhering to the ICAO Annex 13 protocols when and if an investigation is high profile and/or not politically sensitive...

Next on my 'to do' list is to check whether ICAO was notified of this 'serious incident' and sent a copy of the final report...


MTF...P2