By Carrier Pigeon?
Well, no not quite; twas our ever cheerful 'Postie' who dropped the ubiquitous 'brown envelope' into the box. Two sheets of A4 – printed text; related to the ever changing final report into the C441 event, in 2017 which claimed three lives. That was it – of course I read them, then read 'em again. Put them aside – then read through them again. It depends on which corner of the blame game you stand in how you'd translate the missives; but, as an impartial spectator from the back of the room, it is a fascinating match. To the looser, blame will be sheeted home, the winner will toddle off free of blame. The only folks not ferociously represented are the aircrew; the opposition being ATSB, CASA and the Operator, scrambling to avoid the blame and shame. The opening moves of the end game are being made.
I've only clipped some of the lines from the letters: that should be enough for the serious student to see the defences being erected.
“I provide you here with a copy of CASA’s Regulatory and Safety Review in relation to the accident involving VH-XMJ on 30 May 2017.”
“I remind you of the limited objectives of the review, which, by its nature, focuses on particular matters germane to the accident, but which does not, and was not intended to, address causal or contributory considerations.”
Now there is a great surprise – history clearly supports the notion that its easier to stuff a wet noodle in a tigers arse – than get a FOI request met by CASA – yet that above was sent prior to request – voluntary like. That, stand alone raises multiple red flags – why? For whatever reason it was provided you can rule out 'from the goodness in their hearts'.
The ATSB 'addendum' opens a basket of snakes; and also defines a certain odour emanating from the MoU. Like most bad smells, it is the very devil to cover up and its not the first time the whiff of it has been detected during Estimates or 'Inquiry'. However, this time around, it seems that some attempt has been made to eliminate it.
“With respect to the change in the POH procedures applicable to serial number 0173 and onward, the aircraft manufacturer advised that: there was no material difference between the aircraft from serial numbers 0173 and onward and the earlier serial numbers (0172 and prior) that necessitated a different method of simulating an engine failure in the take-off configuration the statements in the earlier POH procedure that referenced the demonstration of VMCA have the same intent as the warning note in the POH for aircraft with serial numbers 0173 and onward, which states this procedure must not be practised at an altitude below 5,000 feet above ground level.”
Then this:-
"The additional information that we have included in the report was the result of feedback we received from one of the involved parties during their review of the draft report.
Specifically, they questioned the validity of the ATSB’s conclusion that Textron intended the same method of simulating an engine failure in the take‑off configuration to be used across all serial numbers of Cessna 441, despite there being variation in the pilot’s operating handbooks (POHs) between 0173 and onward and the earlier serial numbers."
"During the course of the investigation, and as presented in the draft and final report released on 30 April 2020 , the ATSB concluded that the manufacture’s intent had been that simulation of an engine failure in the take-off configuration was not to be practised below 5,000 ft above ground level for all serial numbers of the aircraft (despite the variation in POH wording)."
"Following receipt of the feedback to the draft report, the ATSB sought additional advice from the aircraft manufacturer however, due to the impact of the Coronavirus in the US (widespread shutdown of industry), it was not possible to obtain that advice in a timely manner. Consequently, the decision was made to continue publication of the final report while also continuing to seek input from the manufacturer, with a view to including additional information once the manufacturer’s intent was received."
"Advice was subsequently obtained from the manufacturer, confirming that the ATSB’s interpretation of the POHs was correct and, in the interest of clarity, additional text was added to the investigation report in July 2020 and the amended report provided to the involved parties."
Standing out like the proverbial dog's whatsits are two major items. There are many other sidebars which need to be addressed; several of serious legal weight; but I digress. In essence; like it or not, the manufacturers Pilot Operating Handbook (POH) clearly states the restrictions placed on demonstrating and practising flight at minimum control speed and single engine emergency procedures. “Not below 5000 feet AGL”. Full stop. BUT, the manufacturer quotes 'engine shutdown'; and (I believe) offer a zero thrust setting – which negates the 'shut down' and opens the door to current practice, with which I have no quarrel.
I'd bet my best boots that every single operator of the type simulates EFATO, using 'zero thrust' well below the mandated 5000' bench mark; after becoming airborne, during an instrument approach; during a go around and during routine 'on type' training. The spirit, intent and POH warnings blithely (or legitimately) ignored; for operational expediency, time/money; and, importantly, to satisfy the CASA requirements for training and checking. Statistically, Zero thrust operations have a very good record:- Aye, 'tis a puzzle.
Consider – had both operator and CASA actually read the POH the clear restriction would have been identified. To define and demonstrate an 'equivalent level of safety' with a 'shutdown engine', would require a 'no objection' from the manufacturer, quite a procedure and unlikely to succeed. So all that remain are two words – 'engine shutdown'. It all pivots on whether the engine was 'stopped' or merely restricted, using a simulated 'zero thrust' setting. Which of course raises another 'curly' issue – what if an engine did quit, for real, below 5000' on a dark and stormy night; what then? Is that 'safe?
While the blame is being shuffled about – who is addressing the 'safety case'. I remind you that as yet, there is no clear picture of what actually occurred in that cockpit – none. So, where lay the bare bones of the Ross Air event; lost in the verbiage of “Not me M'lud” perhaps.
“The great enemy of truth is very often not the lie--deliberate, contrived and dishonest--but the myth--persistent, persuasive and unrealistic. Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought. JFK.....
Well, no not quite; twas our ever cheerful 'Postie' who dropped the ubiquitous 'brown envelope' into the box. Two sheets of A4 – printed text; related to the ever changing final report into the C441 event, in 2017 which claimed three lives. That was it – of course I read them, then read 'em again. Put them aside – then read through them again. It depends on which corner of the blame game you stand in how you'd translate the missives; but, as an impartial spectator from the back of the room, it is a fascinating match. To the looser, blame will be sheeted home, the winner will toddle off free of blame. The only folks not ferociously represented are the aircrew; the opposition being ATSB, CASA and the Operator, scrambling to avoid the blame and shame. The opening moves of the end game are being made.
I've only clipped some of the lines from the letters: that should be enough for the serious student to see the defences being erected.
“I provide you here with a copy of CASA’s Regulatory and Safety Review in relation to the accident involving VH-XMJ on 30 May 2017.”
“I remind you of the limited objectives of the review, which, by its nature, focuses on particular matters germane to the accident, but which does not, and was not intended to, address causal or contributory considerations.”
Now there is a great surprise – history clearly supports the notion that its easier to stuff a wet noodle in a tigers arse – than get a FOI request met by CASA – yet that above was sent prior to request – voluntary like. That, stand alone raises multiple red flags – why? For whatever reason it was provided you can rule out 'from the goodness in their hearts'.
The ATSB 'addendum' opens a basket of snakes; and also defines a certain odour emanating from the MoU. Like most bad smells, it is the very devil to cover up and its not the first time the whiff of it has been detected during Estimates or 'Inquiry'. However, this time around, it seems that some attempt has been made to eliminate it.
“With respect to the change in the POH procedures applicable to serial number 0173 and onward, the aircraft manufacturer advised that: there was no material difference between the aircraft from serial numbers 0173 and onward and the earlier serial numbers (0172 and prior) that necessitated a different method of simulating an engine failure in the take-off configuration the statements in the earlier POH procedure that referenced the demonstration of VMCA have the same intent as the warning note in the POH for aircraft with serial numbers 0173 and onward, which states this procedure must not be practised at an altitude below 5,000 feet above ground level.”
Then this:-
"The additional information that we have included in the report was the result of feedback we received from one of the involved parties during their review of the draft report.
Specifically, they questioned the validity of the ATSB’s conclusion that Textron intended the same method of simulating an engine failure in the take‑off configuration to be used across all serial numbers of Cessna 441, despite there being variation in the pilot’s operating handbooks (POHs) between 0173 and onward and the earlier serial numbers."
"During the course of the investigation, and as presented in the draft and final report released on 30 April 2020 , the ATSB concluded that the manufacture’s intent had been that simulation of an engine failure in the take-off configuration was not to be practised below 5,000 ft above ground level for all serial numbers of the aircraft (despite the variation in POH wording)."
"Following receipt of the feedback to the draft report, the ATSB sought additional advice from the aircraft manufacturer however, due to the impact of the Coronavirus in the US (widespread shutdown of industry), it was not possible to obtain that advice in a timely manner. Consequently, the decision was made to continue publication of the final report while also continuing to seek input from the manufacturer, with a view to including additional information once the manufacturer’s intent was received."
"Advice was subsequently obtained from the manufacturer, confirming that the ATSB’s interpretation of the POHs was correct and, in the interest of clarity, additional text was added to the investigation report in July 2020 and the amended report provided to the involved parties."
Standing out like the proverbial dog's whatsits are two major items. There are many other sidebars which need to be addressed; several of serious legal weight; but I digress. In essence; like it or not, the manufacturers Pilot Operating Handbook (POH) clearly states the restrictions placed on demonstrating and practising flight at minimum control speed and single engine emergency procedures. “Not below 5000 feet AGL”. Full stop. BUT, the manufacturer quotes 'engine shutdown'; and (I believe) offer a zero thrust setting – which negates the 'shut down' and opens the door to current practice, with which I have no quarrel.
I'd bet my best boots that every single operator of the type simulates EFATO, using 'zero thrust' well below the mandated 5000' bench mark; after becoming airborne, during an instrument approach; during a go around and during routine 'on type' training. The spirit, intent and POH warnings blithely (or legitimately) ignored; for operational expediency, time/money; and, importantly, to satisfy the CASA requirements for training and checking. Statistically, Zero thrust operations have a very good record:- Aye, 'tis a puzzle.
Consider – had both operator and CASA actually read the POH the clear restriction would have been identified. To define and demonstrate an 'equivalent level of safety' with a 'shutdown engine', would require a 'no objection' from the manufacturer, quite a procedure and unlikely to succeed. So all that remain are two words – 'engine shutdown'. It all pivots on whether the engine was 'stopped' or merely restricted, using a simulated 'zero thrust' setting. Which of course raises another 'curly' issue – what if an engine did quit, for real, below 5000' on a dark and stormy night; what then? Is that 'safe?
While the blame is being shuffled about – who is addressing the 'safety case'. I remind you that as yet, there is no clear picture of what actually occurred in that cockpit – none. So, where lay the bare bones of the Ross Air event; lost in the verbiage of “Not me M'lud” perhaps.
“The great enemy of truth is very often not the lie--deliberate, contrived and dishonest--but the myth--persistent, persuasive and unrealistic. Too often we hold fast to the cliches of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought. JFK.....