[Peetwo]

Can'tberra: Last one to leave - please turn the lights out?

Hmm..I smell a RRAT??

Supplementary Estimates - WQON.

(N.B AQON for Sup Estimates are due 06/12/19)

ATSB:

Question on notice no. 387

Senator Glenn Sterle: asked the Australian Transport Safety Bureau on 8 November
2019—

What is the status of the following investigations?
o AO-2016-084
o AO-2017-066
If these investigations are still classified as "pending", when do you expect them to be
finalised?
Is there a time period within which ATSB would normally expect investigations to be
complete?
In the case of AO-2017-066 why was the aircraft diverted to Perth rather than landing
at its nearest alternative, Learmonth? Is this considered best practice?
In relation to investigation AO-2015-084:
o What recommendations were included in this report?
o Have all recommendations been adopted by the airline?
o Does ATSB hold any concerns about the safety of this airline to operate in
Australia?

P2 - These are the ATSB investigations in the order that Sen Sterle mentions them:
 

AO-2016-084

AO-2017-066

AO-2015-084

In the curious book of passing strange coincidences I note that after 1200 days the AO-2016-084 investigation was officially discontinued on the 7 November 2019 - 

Discontinuation notice published 7 November 2019


Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 26 July 2016, the ATSB commenced an investigation into a loss of separation between a Jetstar Airbus A320 registered VH-VFO and an Air Asia X Airbus A330 registered 9M-XXC, near Gold Coast Airport, Queensland.

The Airbus A330 was departing Gold Coast Airport for Auckland, New Zealand while the A320 was arriving from Avalon, Victoria. Both aircraft were in visual meteorological conditions and the flight crews of both aircraft had the other aircraft in sight.

At the request of air traffic control, the flight crew of the A330 reported the A320 in sight and was instructed to pass behind that aircraft and climb. As the A330 climbed, both flight crew received a Traffic alert and collision avoidance system (TCAS)[1] Resolution advisory (RA).[2]Separation reduced to about 600 ft vertically and 0.35 NM (650 m) laterally. The required separation standard was 1,000 ft and 3 NM (5.6 km).

An Airservices Australia (Airservices) internal investigation into the occurrence identified the following safety issue:

Visual-pilot separation is not applied internationally in Classes A, B and C airspace. This may result in pilots of foreign registered aircraft not being familiar with their requirements and obligations when subject to this form of separation.

In response to the identified issue, safety action was undertaken to:

Review the risks of the application of visual pilot separation as applied to foreign registered aircraft. In determining its ongoing feasibility, with these operators, ensure any identified risks are appropriately managed

That review was conducted and resulted in a recommendation to:

Remove PASS BEHIND as a stand-alone phraseology for assigning pilot visual separation. (Note: could still be used in conjunction with other phraseology e.g. MAINTAIN SEPARATION WITH (AND PASS BEHIND).

The review also recommended that the following rule changes be considered in regard to assigning visual separation:

• Changing phraseology from MAINTAIN SEPARATION WITH to MAINTAIN OWN SEPARATION WITH. (alignment with ICAO phraseology)
• Restricting the use of pilot visual separation for jet traffic to sight and follow scenarios. That is, no ‘pass behind’ for jets.
• Limiting the application of pilot visual separation for foreign registered aircraft to sight and follow situations.

Airservices subsequently advised that it intends to implement the review recommendation and also the phraseology rule change described in the first dot point of the review considerations.

The ATSB reviewed the Airservices reports, safety issues and safety actions. Based on this review, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

  

WTD?  - Funny how the discontinuation notice was issued around the date that the ATSB would have received the QON from Sen Sterle and the RRAT Committee? 


Hmm...I smell a RRAT?? - MTF...P2 

Hmm...yet another one for the AirAsia X dirt file? - UDB! 

Report slams AirAsia X incident decisions and failure to follow procedure

Thai AirAsia X's A330-300 which will be operating Bangkok Brisbane flights from June.

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

6:44PM DECEMBER 19, 2019

The crew of an AirAsia X flight from Sydney to Kuala Lumpur opted to divert to the furtherest airport available when one of the A330’s two engines failed.

An Australian Transport Safety Bureau investigation into the incident on August 16, 2016, revealed a series of misjudgements by pilots who initially failed to recognise the problem.

The final report found that as the Airbus A330 flew over Alice Springs, a shaft failure of the right engine oil pressure pump triggered a level 3 alert requiring immediate crew action.

But instead of following procedures and reducing thrust before shutting the engine down, the pilots increased thrust in the belief the alert was a false indication.

After about four minutes, the engine was returned to normal operations but it soon stalled and then failed completely, resulting in the pilots shutting it down.

At this time the pilots made the decision to divert the aircraft, which was only operating with one of its two engines. But instead of heading to Alice Springs which was 30-minutes away, or Adelaide, 75-minutes away, they chose to go to Melbourne – a flight time of 115 minutes.

“This increased the time that the aircraft was operating in an elevated risk environment,” the ATSB report observed.

On the way to Melbourne, the pilots tried twice to restart the right engine, contrary to the operator’s procedures.

“Despite available evidence and cumulative evidence to the contrary, the flight crew determined that the right engine was not damaged and could be restarted,” said the report.

“Both restart attempts failed.”

ATSB transport safety director Stuart Godley said there were three key safety messages from the investigation.

“Not only does this occurrence demonstrate the importance of flight crews adhering to standard operating procedures when responding to aircraft system alerts, it also highlights that those procedures need to be designed with clarity,” Dr Godley said.

“Further, the investigation report identifies that where there is not a need for an immediate response, that flight crews look at the full contextual and available information before deciding on a plan of action.”

According to the ATSB report, the captain on the flight in question had 8700-hours of flying experience including 2540 on A330-type aircraft. In the 90-days prior to the incident, the captain had logged 244-hours. The first officer had 3265-hours of flying experience.

Since the incident, the Southeast Asia-based low cost carrier has restated the operational requirements for flight crews for engine restarts and diversion decision-making.

AirAsia X has also used the occurrence as the basis for a training package for responding to engine failures, restarting failed engines and diversion decision-making.

And for official version from Dr ATCB (God help us -   ) Godley...

Engine failure incident highlights importance of following procedures


[b]The flight crew of an AirAsia X Airbus A330 did not follow proper procedures when faced with an engine oil pressure warning, attempting to restart the affected engine even after it had failed, as well as electing to divert to Melbourne when the aircraft was considerably closer to two other airports.[/b]

The engine oil pressure warning and subsequent engine failure occurred during a 16 August 2016 scheduled flight from Sydney to Kuala Lumpur, with two flight crew, eight cabin crew and 234 passengers on board. While in cruise near Alice Springs the flight crew received an ‘Engine 2 oil low pressure’ failure alert message, which the ATSB’s subsequent investigation of the event established was due to a shaft failure in the engine’s oil pressure pump.

That alert required immediate crew action comprising of reducing thurst on the affected Rolls-Royce Trent 700 engine to idle and then, in accordance with the Airbus procedure, ‘if [the] warning persists’, shutting down the engine.

Procedures need to be designed with clarity

However, the flight crew probably misinterpreted the term ‘persists’ as requiring they wait a certain period of time to determine if the condition was persisting. As a result, they continued to troubleshoot the failure, rather than shut down the engine.

After monitoring the engine the flight crew formed the view that the warning was the result of a gauge failure. With the intent of further trouble shooting, the crew then increased the engine’s thrust. This led to the engine stalling and ultimately failing.

However, despite evidence to the contrary, the flight crew determined that the failed engine was not damaged and could be restarted.

Consequently, and contrary to the operator’s procedures, the flight crew made two attempts to restart the failed engine, even though there was no safety risk to the aircraft that demanded a restart attempt. Both attempts failed.

Also contrary to the operator’s procedures, the flight crew elected to divert to Melbourne following the engine failure, rather than to closer suitable airports in Alice Springs and Adelaide. Although twin-engined airliners such as the A330 are designed to fly safely on a single engine, this decision increased the time that the aircraft was operating in an elevated risk environment of single-engine operations.

“There are three key safety messages from this investigation,” noted ATSB Director Transport Safety Dr Stuart Godley.

“Not only does this occurrence demonstrate the importance of flight crews adhering to standard operating procedures when responding to aircraft system alerts, it also highlights that those procedures need to be designed with clarity,” Dr Godley said.
“Further, the investigation report identifies that where there is not a need for an immediate response, that flight crews look at the full contextural and available information before deciding on a plan of action.”

Since the incident, AirAsia X restated the operational requirements for flight crews for engine restarts and diversion decision making. Further, the airline has also used the occurrence as the basis for a training package for responding to engine failures, restarting failed engines, and diversion decision making.

[b]Read the report AO-2016-101: Engine failure involving Airbus A330, 9M-XXD, 445 km SE of Alice Springs, South Australia, on 16 August 2016[/b]

Meanwhile, in a parallel hemisphere a long way from the fantasy world of the aviation safety Wizards of Oz, the USA's NTSB quietly gets on with the business of proper ICAO Annex 13 aviation accident investigation...

NTSB_Newsroom
@NTSB_Newsroom
·
8h
NTSB Opens Public Docket, Thursday, Dec. 19, 2019, for investigation of Atlas Air Flight 3591 Cargo Plane Crash; https://go.usa.gov/xp72V

---

Via Avherald:

Crash: Atlas B763 at Houston on Feb 23rd 2019, loss of control on approach

By Simon Hradecky, created Thursday, Dec 19th 2019 16:34Z, last updated Thursday, Dec 19th 2019 18:22Z
On Dec 19th 2019 the NTSB opened their public docket, no preliminary report was released so far.

Editorial notes: Information is spread over a flurry of different group reports and data files. It is thus very difficult to work out what might have contributed to the crash. There is one shout in the CVR transcript, that stands out and does not fit the scenario the aircraft performance study paints. The FO exclaims: "12:38:45.9 CAM-2 (where's) my speed my speed [Spoken in elevated voice.]" What does this mean? Did he lose the speed indication? Did his speed indication go outside the flight envelope prompting the following "stall" calls? Did the first officer refer to his feel rather than the instruments when he called the stall? And why would the captain also provide nose down inputs if his instruments were good just with the first officer shouting, or were the fligt controls still connected with the first officer pushing both yokes forward? But then, why would the captain still provide nose down inputs on the left hand elevator, though to a less extent than the first officer, after the elevators split? How did the Go Around Mode activate? What role played the apparent ADI/HSI failure and the EFIS Switch mentioned by the First Officer, was the switch indeed moved and the indications returned to normal, or was the switch not moved and the first officer saw erroneous data on his ADI/HSI? In summary, the docket does not yet provide any clear indication of all the facts leading to the crash...

Meanwhile downunda Mick Mack has declared Wagga the capital of Australia...

Ref: https://www.canberratimes.com.au/story/6...l-capital/



MTF...P2