[Peetwo]

The Hooded Canary takes the ATSB well "Beyond All Sensible Reason" - 



Long post but there is a point (I hope - ) - the chain of disconnection/evidence: 

A hat trick – of warnings.

There are two ‘deep’ elements which ATSB have not deigned to cover off. Esoteric some would say; others would say it belonged to the new generation; some would consider company culture; there are some who would tag the observations as ego and attitude. To me, the elements above weave a pattern where airmanship, training and experience have been lost in the ‘hype’.

One can, and there is evidence supporting (BA for example) where the ‘problem’ begins with the HR folk. A cardboard cut out of the ideal crew – for company purposes – a ‘type’ if you like. You can, with almost 100% accuracy go to a pub and identify the company the individual’s fly for: won many a beer playing this game. There is little in the way of variation; which, for company purposes, is great. Not so much for having the right stuff somewhere on the flight deck. But, IMO it is a flawed philosophy – good pilots ain’t always ‘good’ corporate citizens – compliant and biddable; nor easily intimidated. A small, but important thread in the pattern.

P2 - The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine

To me this is tale is a warning flag; an indicator of pilot training and thinking error. “descending through heavy rain” – Why was the ‘spark’ not selected to manual (ON) before entering ‘heavy rain’. It should be an automatic action to turn the crackers on – long before entering; same as the icing gear – get it hot and working before – basic common sense. Training, corporate or pilot error? It costs maintenance money to replace the ‘crackers’ – but be buggered if I’d sit and wait five seconds for a relight even once – let alone twice. It took two flame outs before the crew selected ‘ON’. Tea and biscuits on my watch for that crew.  

P2 - A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

We have all done it – thumped one on – hard. Quartering crosswind sneaking in behind; strong gusty conditions etc. But you really need to mess it up to damage an inherently tough airframe. You can – even OEI go around from a very low height – you can also ‘feel’ when the aircraft has become a well trimmed manhole cover and take preventative action; maybe you ‘bang’ it on – but you don’t break it.

P2 - A search of the VARA occurrence database for over speed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO over speed event on descent.

Speed excursions happen – not very often – certainly not with this monotonous regularity. Particularly during a descent phase. There is a great deal of difference between a professional assessment of the conditions and the descent profile being ‘worked’ to suit the ambient conditions, than simply programming the Auto to get you to 1500 feet at five mile from Kickinatinalong. Lots of time spent ‘discussing’ and ‘briefing’ the approach plate – but little on the conditions expected throughout the ‘descent’ phase. Over speed is a training and airmanship matter.

Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching in heavy rain. These three known items may not be potential killers – but by Golly, they are man made holes in that famous Swiss cheese. How this becomes a matter for ATR to solve is beyond my ken; this, before we even get to the meat and spuds of how the control channels became separated in fairly routine conditions between Canberra and Sydney; and, how ATR are expected to re-jig their aircraft to prevent terminal stupidity. More to follow – you can bet on it.

Aye well - back to my knitting. Before I do :-

Cute as a button. Or; funny coincidence department? – You pick. Either way it is a classic of ATSB aberrations; all part of being the PR extension for the big guns. I’m rattling on about the exquisite timing of the ATSB release of the long awaited report into the badly damaged ATR. Go figure the odds; five years and change we waited for the release and when does it happen?
 
Apart from Cready and Oz Aviation – the media completely missed this one; and, there is a story there, a scary one to boot. But what with the world watching the Moscow tragedy and the 737 Max brouhaha and some kind of conference; and, a federal election on the boil - ATSB choose this particular time to quietly slip this report into he public arena. Thing’s that make you go Hmm indeed.
 
Coincidence – not a ducking chance 
 
Toot – toot.

Plus:

Cracks in the ‘deeper’ foundations?

Over the last 12 month; I have, looking through the boarding passes done 20 domestic sectors – four international and four domestic ‘overseas’ - as a passenger. I get about a bit – back and forward to work.

The four overseas sectors were in the USA – lovely smooth landings – as usual from well managed approaches, despite the traffic and schedule – no complaints, operationally whatsoever. The ‘usual’ 'whinges' are purely personal preferences.

Of my domestic sectors – only four were on Virgin; two into Brisbane, two into Sydney. They were the last I ever flew with that airline – totally and utterly the very last. The first ’scare’  was into Brisbane – being sensitive to the handling of the aircraft, my own little alarm started ring about 20 miles out. By 18 miles, the aircraft felt and sounded like there was a ‘speed/ glide-path control problem; by about 14 miles, I was convinced that there was little control over either – hard landing approaching I reckoned. Proved correct – IMO the resulting landing, from that approach was indeed ‘heavy’. I was much surprised to see the aircraft taxi out again about 30 minutes later. When an almost picture perfect repeat of this event happened this occurred, a couple of weeks later; I simply decided not to ever again fly on a line where aircraft were not under complete control during the approach, made earth shattering landings and taxied out ‘on schedule’ after what was, by any reckoning a very hard landing and significant bounce..

I did two sectors with Tiger – no complaint whatsoever, the approach was nicely managed, the landing most acceptable.

The rest I did with Qantas. Same sectors over a three month period – out and back. Not once, was I subjected to a landing I would deem ‘acceptable’. Bang, crash, wallop – big reverse and some fairly sloppy taxi-ing, along with harsh braking.

Now, they ‘discover’ cracks in air- frames – Wow!   I wonder how they happened?

HR have a lot to answer for; profiling to find ‘the right type’ of corporate citizen to fit their mould of ‘what’ makes for a decent pilot. Used to be an ability to actually manage the aircraft – alas; no longer it seems. Not to worry – its all about the ability to type 60 WPM with your left hand and reliance on the ability to manage the software.

Aye, us Dinosaurs must learn to look the other way – toward the blessed day when ‘travel’ is no longer a requirement. Soon, very soon – I won’t have to give a monkeys; or fly anything that is repeatedly ‘slammed onto a runway’ - driven, no matter what – onto the markers at the scheduled speed, rather than ‘flown on’. “Oh, I do ‘em like that all the time” – the old answer to a ‘greaser’ in a fluky crosswind – off a hand flown ILS, middle of the night. Of course it was a fluke  - but I have ‘fluked’ it quite a lot of times. Enough to know the difference anyway. Not my problem - as are the repair and rectification bills.

Just saying my two bob’s worth – cracks in airframes ain’t a good thing; are they? However, now is the time for all good men of legal age to imbibe. BRB full session to ‘manage’ – the boy wants his new keyboard back – time for a quiet, calm, reflective Ale, before the BRB/IOS storm.

Yesterday the ATSB finally released their report into the ATR heavy landing at Canberra airport - 

  Via the Oz:

Virgin plane damaged after pilots’ stuff-up



The pilots of a Virgin Australia aircraft that landed so hard it was substantially damaged, were undergoing flight checks at the time, an Australian Transport Safety Bureau investigation has revealed.

The ATSB’s final report on the incident at Canberra Airport on November 19, 2017, found the pilots failed to adhere to standard operating procedures as the ATR 72 descended.

To make matters worse, a check captain was on the flight deck conducting an annual line check of the captain and a six-month check of the first officer.

According to the report, just four seconds from landing, the aircraft was descending at a rate of 784 feet per minute – or more than 200 feet per minute above the normal descent rate.

“At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component,” the report said.

“This resulted in a further loss of lift and the captain later stated he felt the aircraft drop out from under him.”

READ MORE: Qantas tests London to Sydney | Rex gets go ahead for foreign pilots

As a result, the turboprop reached a recorded 928-feet per minute descent rate at touchdown, resulting in a 2.97G hard landing on the main landing gear, tail skid and underside of the rear fuselage. All were substantially damaged.

The ATSB investigation found the power was incorrectly set for descent, but despite calling twice for an increase, the captain who was the pilot monitoring, did not physically intervene until it was too late.

The call for a go-around was made just as the aircraft touched down. Fortunately none of the 67 passengers or five crew on board were hurt.

ATSB transport safety executive director Nat Nagy said the crew should have conducted a go-around when the approach became unstable.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures,” Mr Nagy said.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

He noted that unstable approaches continued to be a leading contributor to approach and landing accidents, and runway excursions or overruns.

The report revealed the captain had more than 8000-hours of flying experience and the first officer, 1320-hours.

In response to the incident, Virgin Australia had amended ATR 72 operational documentation, and reinforced existing training regarding speed management during approach and landing.

 
And the accompanying Hooded Canary MR: 

Unstable approach, failure to go-around leads to a hard landing


[b]The ATSB is highlighting the importance of adhering to standard operating procedures following the release of a final investigation report into the hard landing of an ATR 72 airliner resulting from an unstable approach.[/b]

On 10 November 2017, ATR 72-212A VH-FVZ operating as Virgin Australia flight VA646 was arriving at Canberra Airport in conditions of light turbulence. On the flight deck were the captain (who was also a training captain), the first officer (who the captain had previously trained), and a check captain. The check captain was conducting a routine annual operational line check of the captain and a six-month operational line check of the first officer over four flights on the day. The occurrence flight was the last of these flights. In the main cabin were two cabin crew members and 67 passengers.

During the landing approach the first officer, who was the pilot flying, assessed that the aircraft was overshooting the desired approach profile. In response, at a height of 118 feet above the runway, he reduced engine power to idle, but this resulted in an abnormally high descent rate (in turboprop aircraft large propellers spinning rapidly in low pitch create a significant increase in drag).

The aircraft captain, who was the pilot monitoring, identified that power was incorrectly set, and twice called for an increase in power before subsequently intervening and increasing power himself. This intervention, however, occurred too late to arrest the high rate of descent.

Four seconds prior to touching down, the aircraft was descending at a rate of 784 feet/minute, already greater than the design limit of the undercarriage and above the normal descent rate for the approach of about 575 feet per minute. At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

Consequently the aircraft reached a recorded 928 feet per minute descent rate at touchdown, resulting in a 2.97 G hard landing on the main landing gear, tail skid and underside of the rear fuselage, resulting in substantial damage.

Unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

The aircraft subsequently required inspection of landing gear components, reskinning of sections of the fuselage underside, and replacement of the tail skid and a drain deflector mast before it could return to service.

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures and conducting a go-around when an approach becomes unstable.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions. No shit Sherlock -  

[b]Read the report AO-2017-111: Hard landing involving ATR 72, VH-FVZ, Canberra Airport, Australian Capital Territory on 19 November 2017[/b]

Which brings me to this O&O'd / yet to be completed, investigation within a completed investigation...  

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

...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.
  

 
Note that the last update states the expected completion of this investigation as the '1st Quarter 2020' but the investigation status is only listed as 'evidence collection', so early 2020 is optimistic at best ...   Shirley, given the above evidence the Hooded Canary could put a little bit more priority towards completing that investigation...  

This brings me to the other former high profile completed investigation that has an associated investigation within an investigation: https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/   

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

..On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.


The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.

  
To which I add this post link which highlights the snail pace progress of yet another investigation that you would think would have a much higher priority : Strange dissonance in the Hooded Canary's coop? - Part II

...The Essendon crash deserved the ATSB’s very best efforts; it could have been a serious disaster, with magnified ramifications. Yet it was quickly concluded that it was all pilot error, nothing to see and the ATSB would concentrate on whether the building measured up to ‘Black letter’ approval. For starters, ATSB are not in the ‘airspace game’ nor are they forensic legal experts on ‘approval’ to build, particularly in light of the convoluted processes used. So why was the aircraft and pilot quickly dismissed in favour of some half-baked ‘investigation into what Hood claims was a ‘life-saving’ building. It’s bollocks – ATSB’s job is to tell us, as best they can, from the charred remains – why this aircraft crashed and claimed five lives; difficult as that maybe... 

&..from this Airports thread post: A duty of care. - Part II

3)

Patrick Hatch article: ..The Australian Transport Safety Bureau found that pilot error was to blame, but while looking into the crash, decided to launch a separate investigation into how the DFO complex was approved "from an aviation safety perspective".

That probe is nearing completion, with its final report currently out for review by the parties involved ahead of its public release...

Hmm...why do I get the impression that not only are the powers to be actively avoiding addressing the significant holes in the Swiss cheese that these high profile accident investigations have identified but are also actively engaging in contributing to making the holes bigger to help facilitate the next high profile accident?   



 

MTF...P2