[Peetwo]

Joining the dots on Fort Fumble's 18 year obfuscation of ATSB identified Night VFR safety issue - 

To begin I would like first to refer to what is IMO two of the better and (unfortunately these days) rare examples of a truly systemic, (based on the Reason model) AAI investigations: 
1) https://www.atsb.gov.au/media/4462266/ao..._final.pdf
2) https://www.atsb.gov.au/media/5668844/AO...0Final.pdf

No1. was of course the first AF fatal accident in 2011, involving Piper Cherokee VH-POJ and No2 was the high profile ATSB AAI into the fatal crash of an ABC squirrel helicopter at Lake Eyre that occurred 3 day after the VH-POJ crash.  

To set the scene, before joining the dots in with what is now IMO clearly a joint CASA/ATSB smokescreen, the following is extracts from page 15 and 16 of the No1. report:

---

IMO the above extract is a clear example of how the ICAO Annex 13 AAI system is supposed to work -    Perhaps in the real world of international Annex 13 aviation safety investigation the ATSB would issue a similar safety recommendation to Angel Flight in conjunction with the soon to be released Final Report into the tragic crash of VH-YTM near Mount Gambier?  

However the odds of that happening are IMO extremely remote given the continued attempted embuggerance of AF by St Carmody and his Iron Ring minions -  

Back to joining the dots...

On the same page of the No1. report there was also attention brought to another NTSB SR:

 

United States occurrences

Safety Alert

In March 2013 the United States (US) National Transportation Safety Board (NTSB) issued Safety Alert SA-020 Reduced Visual References Require Vigilance. This alert highlighted that about two thirds of US general aviation accidents in reduced visibility weather conditions are fatal, and typically involve pilot disorientation or controlled flight into terrain. The NTSB observed that even in visual conditions, the combination of flight at night with limited ground lighting and therefore ground references could be problematic.

A number of common accident scenarios in conditions with limited ground reference were provided in the alert and strategies for pilots to manage that risk were suggested. Of note in the context of the accident near Horsham on 15 August 2011, the NTSB highlighted that:

Remote areas with limited ground lighting provide limited visual references [sic] cues for pilots, which can be disorienting…
and that pilots should:

Consider following instrument procedures if you are rated or avoiding areas with limited ground lighting (such as remote or mountainous areas) if you are not.

And from the 'safety analysis' section of the report, this was the ATSB's comments in relation to the NTSB Safety Alert:

Other efforts to reduce the risk of night operations

The United States National Transportation Safety Board (NTSB) recently issued Safety Alert SA-020 Reduced Visual References Require Vigilance. The alert included the following guidance:

Remember that, when flying at night, even visual weather conditions can be challenging. Remote areas with limited ground lighting provide limited visual references cues for pilots, which can be disorienting or render rising terrain visually imperceptible. When planning a night flight, use topographical references to familiarize yourself with surrounding terrain. Consider following instrument procedures if you are rated or avoiding areas with limited ground lighting (such as remote or mountainous areas) if you are not.

The ATSB strongly supports such guidance, and advises all operators and pilots considering night flights under the VFR to systematically assess the potential for the flight to encounter dark night conditions by considering weather conditions, celestial illumination and available terrain lighting. If there is a likelihood of dark night conditions, the flight should only be conducted by a pilot having a high degree of instrument flying proficiency in an aircraft that is equipped to a similar standard.

Consequently, with the NTSB SA in mind, backed by the findings gathered in the VH-POJ investigation, it is highly probable that this was what led the ATSB to follow up with a rare but important safety recommendation, that was titled Requirements for visual flight rules flights in dark night conditions: ref - https://www.atsb.gov.au/publications/inv...100/si-01/

Ironically this is where the two reports (No1. & No2.) intrinsically come together - quote from the si-01 link above:

ATSB response:

This safety issue and report of safety action by CASA in response reflects that reported in ATSB safety investigation report AO-2011-102. The ATSB welcomes the intent of this proposed action by CASA in response to this safety issue. In particular, the ATSB agrees that expanding what is meant by the term ‘visibility’ at night to include the requirement for a visual horizon will help ensure that pilots operating under the night VFR will have sufficient visual cues. However, as discussed in investigation report AO-2011-102, given the importance of the safety issue, the ATSB is concerned about the indefinite nature of the proposed evaluation and other exploratory activities proposed by CASA.

As a result of this concern, the ATSB issued safety recommendation AO-2011-102-SR-059 to CASA on 8 November 2013. Although specifically referring to investigation AO-2011-102, this safety recommendation will, when adequately addressed, also address safety issue AO‑2011‑100-SI-01 in respect of the accident involving VH-POJ, 31 km north of Horsham Airport, Victoria on 15 August 2011. The safety recommendation is therefore repeated below for ease of reference.

This is the link for AO-2011-102-SR-059: https://www.atsb.gov.au/publications/inv...102-si-02/

Recommendation

Action organisation: Civil Aviation Safety Authority
Action number: AO-2011-102-SR-059
Date: 08 November 2013
Action status: Monitor

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority prioritise its efforts to address the safety risk associated with aerial work and private flights as permitted under the visual flight rules in dark night conditions, which are effectively the same as instrument meteorological conditions, but without sufficient requirements for proficiency checks and recent experience to enable flight solely by reference to the flight instruments.

---

Correspondence
Date received: 07 February 2014
Response from: Civil Aviation Safety Authority
Action status: Monitor

Response text:

CASA partially accepts the recommendation in as much as regulation 61.970 of the Civil Aviation Safety Regulations 1998 (CASR) requires pilots to demonstrate competency during biennial night visual flight rules assessments. The regulation was made in February 2013 and commences in September 2014.

In addition, CASA also commenced a project on 16 December 2013, OS 14/01 Night Visual Flight Rules. This will consider whether to require a discernible external horizon during flights under Night Visual Flight Rules (NVFR). CASA proposes to clarify the definition of visibility in regulation 2 of the Civil Aviation Regulations 1988 (CAR) to ensure the primary coincident safety issue above is dealt with. CAR 2 defines visibility as the "ability, as determined by atmospheric conditions and expressed in units of distance, to see and identify prominent unlighted objects by day and prominent lighted objects by night". Project OS 14/01 CASA will consider whether to seek an amendment to this definition by adding to it the requirement that for NVFR, the determination of visibility must also include the ability to see a defined natural horizon. This will in effect address the root cause of the matters outlined in the safety issue as pilots will need to have a discernible horizon throughout their flight. If a discernable horizon is not present then the flight should be conducted under the Instrument Flight Rules (IFR) and all associated regulations for IFR flight will apply.

The project will also review the current NVFR regulatory requirements and CASR definitions to ensure it limits the visual environment to that in which a defined external horizon is available for aircraft attitude control. The project will examine the night VMC requirements for both rotorcraft and aeroplanes. However the outcome of the project may limit the change to the night VMC requirements to rotorcraft only in recognition of the difference in certification requirements between the categories. The project will also amend the guidance provided in CAAP 5.13-2 to emphasise the importance of maintaining a discernible external horizon at night particularly in light of the certification basis for NVFR rotorcraft.

ATSB response:

The ATSB recognises CASA’s ongoing efforts to address this safety issue.

Date received: 24 October 2016
Response from: CASA
Action status: Monitor
Response text:

CASA partially accepted the recommendation and advised the ATSB in February 2014 that regulation 61.970 of the Civil Aviation Safety Regulations 1998 (CASR) requires pilots to demonstrate competency during biennial night visual flight rules assessments. The regulation was made in February 2013 and commenced in September 2014.

In addition, on 16 December 2013, CASA advised the ATSB that we had commenced project OS 14/01 Night Visual Flight Rules. This considered whether to require a discernible external horizon during flights under Night Visual Flight Rules (NVFR) and whether to amend the definition of visibility in regulation 2 of the Civil Aviation Regulations 1988 (CAR).

The project also reviewed the current NVFR regulatory requirements including CASR definitions and examined the NVMC requirements for both rotorcraft and aeroplanes. The project also proposed to amend the guidance provided in Civil Aviation Advisory Publication (CAAP) 5.13-2 to emphasise the importance of maintaining a discernible external horizon at night particularly in light of the certification basis for NVFR rotorcraft.

The outcomes of the project were limited to rotorcraft only in recognition of the difference in certification requirements between rotorcraft and aeroplanes.

As a result of this project I would like to advise that CASA has taken the following actions:

CAAP 5.13-2 was withdrawn and Advisory Circular (AC) 61-05 Night VFR Rating was published in April 2016 to provide information on the certification criteria for helicopters under the NVFR and the importance of maintaining sufficient visual cues for aircraft attitude control in light of the certification requirements (at section 6.5), and
On 27 April 2015, Civil Aviation Order 20.18 Amendment Instrument 2015 (No. 2) was made and commenced on 1 January 2016. The amendment instrument inserted a new paragraph 3.2A into CAO 201.18, to clarify that a helicopter may only be operated under V.F.R. at night if equipped with: the instruments specified in Appendix VIII of the CAO; and any other instruments and indicators specified in the helicopter's flight manual. It also required that if the helicopter's attitude cannot be maintained by visual external surface cues, the helicopter must be equipped in accordance with subparagraph 4.2 (d) of CAO 20.18 regarding an automatic pilot or automatic stabilisation system, or be operated by a qualified 2-pilot crew.
CASA considers this safety recommendation has been addressed and requests that this advice be published on the ATSB website

ATSB response:

On 24 October 2016, CASA advised the ATSB that it considers Safety recommendation AO- 2011-102-SR-059 had been fully addressed. While acknowledging the safety actions undertaken by CASA, the ATSB remains concerned about instrument proficiency, and visibility requirements for fixed-wing operations at night.

The ATSB welcomes the introduction of a biennial flight review for the night VFR rating, however does not consider that it fully supports the safety recommendation as there is no formal ongoing requirement to maintain instrument flying proficiency and currency.

CASA has addressed night visibility flight requirements for helicopter flights by amending AC 61-05 (section 6.5.5.1) and CAO 20.18 (section 3.2A ©) however the ATSB is concerned the same standards do not apply to fixed-wing operational equipment. This relates directly to the safety issue raised as a result of another VFR flight into dark night accident investigated by the ATSB (AO-2011-100).

Based on CASA's actions to date, the ATSB intends to publish CASA's response on its website and retain the current status of safety recommendation AO-2011-102-SR-059 as 'Monitor'.

Current issue status: Safety action pending

Status justification:

The ATSB recognises CASA’s ongoing efforts to address this safety issue.

Note that both of the SR's are still open and the status is listed as 'safety action pending' -  

Okay let's go back to the No1. report and on page 13 under 'Related Occurrences' is listed...

Collision with terrain 3 km east of Newman Airport, Western Australia on 26 January 2001 – ATSB investigation BO/200100348

ATSB investigation BO/200100348 examined the circumstances of the collision with terrain that occurred 3 km east of Newman Airport, Western Australia on 26 January 2001 and involved a Cessna 310R aircraft, registered VH-HCP. The flight was conducted at night under the VFR, with one pilot and three passengers on board. All were fatally injured and the aircraft destroyed.

During its investigation the ATSB identified a safety issue in respect of the requirements for pilots to maintain currency, recency and proficiency for night VFR flight under dark night conditions. In consequence, on 23 October 2002, the ATSB issued safety recommendation R20020193 that stated:

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority (CASA) review the general operational requirements, training requirements, flight planning requirements and guidance material provided to pilots conducting VFR operations in dark night conditions.

In response to this recommendation, on 13 December 2002, CASA advised that:

CASA acknowledges the intent of this Recommendation. As part of the proposed CASR Part 61, CASA is developing the requirements for night VFR ratings which will be based on the existing Civil Aviation Order CAO 40.2.2. In addition, a draft competency standard for night visual flight operations has been developed for inclusion in the proposed CASR Part 61 Manual of Standards. CASA plans to publish a Notice of Proposed Rule Making in relation to this matter in March 2003.

Collision with water off Cape Hillsborough, Queensland on 17 October 2003 – ATSB investigation 200304282

At about 2132 on 17 October 2003, a Bell 407 helicopter, registered VH-HTD departed Mackay Airport for Hamilton Island, Queensland (Qld) with the pilot, a crewman and a paramedic on board. The pilot transmitted a departure report for the night VFR flight and submitted an estimated time of arrival for Hamilton Island. No additional communication was received from the pilot and a subsequent search identified aircraft wreckage floating in the sea off Cape Hillsborough. The aircraft occupants were fatally injured and the helicopter destroyed on impact.

As part of its investigation into this accident, on 6 November 2003, the ATSB issued safety recommendation R20030213 to CASA recommending:

…that the Civil Aviation Safety Authority review the night visual flight requirements and promulgate information to pilots emphasising the importance, during flight planning, of considering whether:

• environmental conditions allow for aircraft orientation by visual reference alone,
• there is likely to be sufficient ground or natural lighting and flight visibility along the proposed route to provide visual reference to the ground and/or water during the flight, and
• they are capable of safely operating the aircraft should non-visual conditions be encountered.

CASA responded to R20030213 on 10 December 2003 and stated, in part that:

CASA supports the issues raised in the Air Safety Recommendation and advises that the Authority is currently reviewing the night visual flight requirements with a view to emphasising to pilots, through its safety promotion activities, the importance of considering the above factors.

On 21 December 2004, CASA further responded to the recommendation and advised:

CASA does not agree that a review of night VFR requirements is necessary. Firstly, regulations specify that weather conditions of night VFR must be such that a planned flight can be conducted at a safe height clear of cloud. With respect to pilot competency, Civil Aviation Order (CAO) 40.2.2 specifies that the night VFR rating requires pilot be trained to control an aircraft solely by reference to instruments. Any notion that celestial lighting and/or an apparent visible horizon are appropriate references for the control of an aircraft by night is misleading and dangerous and increases the probability of pilot disorientation.

On 27 January 2005, after being asked for clarification on the issue, CASA responded:

Reliance on ambient lighting at night rather than instruments for attitude reference is potentially hazardous due to the high risk of pilot disorientation. CASA strongly believes that the requirements specified in Civil Aviation Order (CAO) 40.2.2 are adequate for night VFR operations. It is the responsibility of the operators to ensure that pilots meet the requirements specified for rating issue, especially those related to instrument flying. Therefore, CASA does not believe that a review of these requirements is necessary given that Australia already has the most comprehensive night VFR pilot qualification.

 

And that my Dear Watson IMO are some pretty big and damning DOTS...


MTF? - Yes much!...P2