[Peetwo]

RAAus v ATSB: Occurrence reporting disconnections? 

References:

P7’ s Opinion – delivered; as requested.

“Given the size and scope of the RA Oz ‘incident and accident’ list; reading through the responses made to those events; we thought it may germane to take a closer look. ‘K’ is still fuming over the following, to cranky to be impartial. “Can you do it?” Well I’m as appalled as he, however; I’ll take a shot. Lets see”.

Plus:

...Next I have a QoN for Hitch off Oz Flying - http://www.australianflying.com.au/lates...n-approval - in relation this para??

..ASQA's decision is being seen as another blow for Soar after a string of incidents including crashes of Bristells at Stawell and Moorabbin and another incident at Drouin, Victoria, on Christmas Eve when a Bristell struck trees during a practice forced landing...

Where did you get the underlined information from? The reason being that I have checked both the RAAus - Accident & defect summary - and the ATSB aviation occurrence database without any success in tracking down that particular incident??

However as an aside, while trolling through those latest RAAus incidents, I was disturbed by the number of a) reported incidents (30 from 1 December 2019 to today) and the naive admissions of b) very poor airmanship, basic aeronautical knowledge and blatant disregard for the rules...  

This one was most disturbing:     

...Inadvertent flight into IMC: The aircraft departed Narromine into significant smoke haze. At 500' the pilot could see objects out to about 10NM but could not see the horizon. At cruise altitude of 4,500' visibility became worse. The visual cues indicating the aircraft's attitude became degraded. The pilot could judge pitch and roll only by looking at the paddocks and roads within a 45 degree cone beneath the aircraft. When they were head-down looking up the latest weather details for their next stop at Griffith the pilot glanced sideways at the ground to see if they were still wings-level and all seemed OK until they saw the artificial horizon on the EFIS which indicated that they were in a 15 degree bank. The pilot knew then what IMC was they then engaged the autopilot so the next time they were head-down in the cockpit they weren’t going to give themselves another fright. The smoke progressively thinned out towards Griffith and visibility entering the circuit was satisfactory until initiating their turn to base. The pilot seemed to have descended into a lens of smoke which totally blocked their view of the runway, but views crosswind and downwind were relatively clear. The pilot estimated where the extended centreline of the runway was and turned final only to find, when exiting the smoke lens, that they had turned too soon, requiring a dog-leg correction to get back on the centreline...

 
Now I know that the basic RAAus aircraft are only allowed to carry two POB outside of radar CTA but in hindsight if you were the miniscule responsible for oversighting aviation safety would you be prepared to actively promote an aviation business flogging around in aircraft not properly certified for the purposes of training young pilots to fly, while overflying large built up urban areas adjacent to secondary airports that you are also ultimately responsible for...  

Other than the possible nomination for this year's Darwin awards (see posts above) I decided on taking a bit of a closer look see at the RAAus 'Accident and defect summary' webpage which I can only assume is an integral part of the association's SMS which (depending on the seriousness of the accident/incident) by design should be tied to the ATSB National Aviation Occurrence database and ultimately approved by CASA?

With a short bit of digging on the RAAus website I was able to establish that RAAus do facilitate, indeed take responsibility for, the forwarding of mandatory occurrence reports to the ATSB - see HERE:

Recreational Aviation Australia is required to meet statutory reporting requirements under the Transport Safety Investigation Act 2003.

Reportable matters are categorised as:

IRM: Immediately reportable matters

RRM: Routinely reportable matters

By submitting a report we are able to submit your information directly to the Australian Transport Safety Bureau.

Click below to acknowledge your approval for Recreational Aviation Australia to submit the report to the Australian Transport Safety Bureau on behalf of you.

From the ATSB website, this is the loosely defined definitions for IRMs & RRPs:

What is an immediately reportable matter?

ANSWER:
An immediately reportable matter is a serious transport safety matter that covers occurrences such as accidents involving death, serious injury, destruction of, or serious damage to vehicles or property or when an accident nearly occurred. Under section 18 of the TSI Act, immediately reportable matters must be reported to a nominated official by a responsible person as soon as is reasonably practical. The reason for such a requirement is the need for ATSB investigators to act as quickly as possible is often paramount in order to preserve valuable evidence and thus to determine the proximal and underlying factors that led to a serious occurrence.
The list of immediately reportable matters for each mode of transport is contained in the TSI Regulations. Immediately reportable matters are the only transport safety matters that need to be reported for the marine mode of transport. In aviation and rail where the Commonwealth, and hence the ATSB, has more comprehensive responsibilities for the investigation of transport safety matters there is also a list of routine reportable matters.

What is a routine reportable matter?

ANSWER:
A routine reportable matter is a transport safety matter that has not had a serious outcome and does not require an immediate report but transport safety was affected or could have been affected. Under section 19 of the TSI Act a responsible person who has knowledge of a routine reportable matter must report it within 72 hours with a written report to a nominated official.
The list of routine reportable matters are contained in the TSI Regulations. Routine reportable matters only exist for aviation and rail and would include a non-serious injury or the aviation or rail vehicle suffering minor damage or structural failure that does not significantly affect the structural integrity, performance characteristics of the vehicle and does not require major repair or replacement of the affected components.

Routine reportable matters exist only for aviation and rail as the Commonwealth has wide ranging responsibilities for aviation matters because of the nature of the industry in which all aircraft are subject to the same control. In the marine transport mode the ATSB concentrates on serious safety matters in relation to international and/or interstate transport only as the Commonwealth does not have sole responsibility for these modes.

---

And from the TSI Act:

 All aircraft operations

         (1)   For the purposes of the definition of immediately reportable matter in subsection 3 (1) of the Act, the following investigable matters, in relation to an aircraft operation (other than an aircraft operation mentioned in subregulation 2.1 (2)), are prescribed:

                (a)    subject to subregulation (2), the death of, or a serious injury to:

                          (i)    a person on board the aircraft or in contact with the aircraft or anything attached to the aircraft or anything that has become detached from the aircraft; or

                         (ii)    a person who has been directly exposed to jet blast;

               (b)    the aircraft being missing;

                ©    the aircraft suffering serious damage, or the existence of reasonable grounds for believing that the aircraft has suffered serious damage;

               (d)    the aircraft being inaccessible and the existence of reasonable grounds for believing that the aircraft has been seriously damaged;

                (e)    breakdown of separation standards, being a failure to maintain a recognised separation standard (vertical, lateral or longitudinal) between aircraft that are being provided with an air traffic service separation service.


Aircraft operations other than air transport operations

         (2)   For the purposes of the definition of routine reportable matter in subsection 3 (1) of the Act, the following investigable matters, in relation to an aircraft operation (other than an aircraft operation mentioned in subregulation 2.1 (2) or an air transport operation), are prescribed:

                (a)    an injury, other than a serious injury, to a person on board the aircraft;

               (b)    a flight crew member becoming incapacitated while operating the aircraft;

                ©    airprox;

               (d)    an occurrence in which flight into terrain is narrowly avoided;

                (e)    the use of any procedure for overcoming an emergency;

                (f)    an occurrence that results in difficulty controlling the aircraft, including any of the following occurrences:

                          (i)    an aircraft system failure;

                         (ii)    a weather phenomenon;

                        (iii)    operation outside the aircraft’s approved flight envelope;

               (g)    fuel exhaustion;

               (h)    the aircraft’s supply of useable fuel becoming so low (whether or not as a result of fuel starvation) that the safety of the aircraft is compromised;

                (i)    a collision with an animal, including a bird, on a licensed aerodrome.

Now although some of the 30 odd A&D summaries from the 1sr December 2019 to now certainly don't meet the requirements for mandatory reporting, there are IMO significant number that do and therefore should be reflected/recorded on the ATSB aviation occurrence database.

This of course took me to the ATSB database search page, where I put in the same time frame for reported accident/incidents and came up with the following Excel spreadsheet link: https://auntypru.com/wp-content/uploads/...lts-1.xlsx

A basic summary of that file reads as there being a total of 43 reported occurrences, 18 of which were accidents, 15 being incidents of which 10 were classified as serious and of those 43 occurrences the ATSB will be investigating 7.

All good so far? Now let's go back to the 31 entries (spread over 3 pages) for the same time frame (ie 1 December to today) of the RAAus A&D summaries and apply the ATSB mandatory reporting filters for IRMs & RRMs.

To test the integrity for what would definitely be classified as an IRM, on the 16 December there was a fatal accident involving a Bristill (BRM Aero) aircraft:

Fatal Accident involving RAAus member. RAAus accident consultants are assisting police in determining the causal factors that led to the accident.

     
Which we see corresponds to the ATSB spreadsheet: 

Okay integrity tested, next we will go to the 1st entry for the time frame off the A&D pages, which I would of thought still met the requirements for an IRM?

The aircraft lost power at 4000ft with the engine reduced to idle (900 RPM). The option was taken to return to the airport. Carb heat was applied for icing and a forced landing procedure was enacted. A best L/D is achieved at 70kts. RWY 23 became unachievable with a stronger wind of 15-20kts. The engine remained at idle till switches were cut at 200ft AGL. The undercarriage struck a fence with the aircraft at stall point resulting in the aircraft impacting the ground nose first however it did not become inverted.

However off the ATSB webpage there would appear to be no record for the 72 hours post accident:



Hmm...so maybe it was lost in the mail?

Next entry for the 1st of December reads:

Whilst conducting circuits at YSBK RWY 29L. The Bristell was following a Sling which was marginally slower and performing circuits wider than theirs. Upon unsuccessfully attempting to create sufficient spacing Tower directed the Bristell to perform a go around. The go around was performed and attempts were made to climb and divert to the left side of RWY 29L however the pilot did not divert enough to create sufficient spacing.

Although possibly not an IRM, it definitely meets the requirements for a RRM and as can be seen at this point in time it is not recorded on the ATSB database. Again maybe lost in the mail??

Next we go to the 3rd of December A&D entry:

On landing in the flare there was a wind gust. The aeroplane sank quite fast and bounced. The pilot applied full power to go around. The second landing was successful with a smooth touch down but the pilot struggled with directional control. The pilot got the aircraft back under control but on return to the hangar it was found that the propeller tips had struck the ground.

  
By definition at least an RRM but again no entry?

Next to the 1st page and entry for what was presumably a Soar Aviation aircraft:

At PIPS, the student noted the master caution light come on and start flashing. Passing Carrum, the student descended to 1000 approaching Mordialloc pier and started noticing a blank noise. Student conducted radio failure check to confirm whether they actually had a failure or not. Student took it as a radio failure. Transmitting blind, they squawked 7600 then made call joining downwind RWY17R, did not hear any response. Joining base, the student heard static and then the tower respond and the radio came back live again. The student was advised to change transponder back to 3000 which they did and they were given landing clearance and landed safely.

 
Again possibly not an IRM but because it involved ATC and a recognised emergency procedure, I would have thought at least a RRM should have been submitted but again no report recorded.

Next I'll skip to the New Year and an entry for the 10th of January with yet another Jabiru engine failure:

The aircraft experienced a severe engine vibration followed by complete engine failure whilst on downwind RWY 03. The pilot conducted a successful forced landing on RWY 03.

  
Again the same result - NO ENTRY???

I could go on...and on...but I think that most people with at least half a brain get the message...  

MTF...P2 

Ps Oh and by the way - it should not come as any surprise that the BRB nomination for this year's Darwin awards has also not been submitted to the ATSB??

So we bury him; then we look to the accident investigation for guidance and find twaddle like this:-


..."Inadvertent flight into IMC: The aircraft departed Narromine into significant smoke haze. At 500' the pilot could see objects out to about 10NM but could not see the horizon. At cruise altitude of 4,500' visibility became worse. The visual cues indicating the aircraft's attitude became degraded. The pilot could judge pitch and roll only by looking at the paddocks and roads within a 45 degree cone beneath the aircraft. When they were head-down looking up the latest weather details for their next stop at Griffith the pilot glanced sideways at the ground to see if they were still wings-level and all seemed OK until they saw the artificial horizon on the EFIS which indicated that they were in a 15 degree bank. The pilot knew then what IMC was they then engaged the autopilot so the next time they were head-down in the cockpit they weren’t going to give themselves another fright. The smoke progressively thinned out towards Griffith and visibility entering the circuit was satisfactory until initiating their turn to base. The pilot seemed to have descended into a lens of smoke which totally blocked their view of the runway, but views crosswind and downwind were relatively clear. The pilot estimated where the extended centreline of the runway was and turned final only to find, when exiting the smoke lens, that they had turned too soon, requiring a dog-leg correction to get back on the centreline...

That is an example of ‘internal’ investigation?

What the minister has sanctioned, what CASA have encouraged to develop and what has been taken advantage of demands immediate inquiry. IMO the AFP need to become involved and the inquiry needs to be oversighted and completed by an independent chair. This situation is wrong on so many levels, particularly when the likes of Angel Flight and Buckley are being beaten into the ground. I say enough is enough; time to stop the merry go-round. Start by disillusioning the minister.

 
Hmm...what was that St Commode said in relation to a VFR into IMC accident - 

Ref: https://auntypru.com/sbg-3-03-2019-or-ra...less-vain/