Signposts - to Perdition?
Towards the middle of the P2 post - HERE - you will find a short paragraph - which is the beginning of a bread crumb trail. It is an interesting trail to those genuinely interested 'real' safety matters, rather than the legal/political aspects of accident investigation and reporting. The links provided take you on an 'interesting' journey through the twisted pathways leading to the 'nothing to see - move along' Jedi mind trick. But there is much to see, non of it worth the cost..
P2 - "This brings me to the safety issues section of the FR and in particular under the heading of 'Regulatory surveillance – scoping of surveillance events"....
Snipe and counter snipe artfully disguised to cover over the indolence, arrogance and ineptitude of two very expensive 'safety' authorities. Masters of disingenuous obfuscation and good old fashioned arse covering.
ATSB. - "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 on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator".
Discontinued; time, money and effort wasted with no positive reporting aimed toward preventing similar 'attitudes' toward 'how' a company should operate etc. No useful stuff like redefining 'command' prerogative and authority. Not even a mention of the piss poor descent planning and monitoring leading to a panic induced lack of cockpit discipline. One could (ATSB should) strip the ATR event back to company culture, aircrew selection and training: and, management 'requirements' on the crew. There is food for thought there, but now, beyond the ambit of ATSB discussion or interest. 'Nuff said..
For us, it's time to pay a visit to the flight deck. We can start a few minutes before Top of Descent;
ATSB - "As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, 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". (abuse of language).
Clearance and ATIS noted, briefing complete; power back and, down we go - standard rate; a tick short of 'red line' speed, which is unwise, as we discover.
"While passing through about 8,500 ft, the aircraft encountered a significant windshear that resulted in a rapidly decreasing tailwind". Bollocks; try the inversion on for size. WTD has a 'rapidly decreasing tail wind got to do with it; rubbish! Ground speed :: Airspeed? Ring any bells?
"This led to a rapid (15 small knots?) increase in airspeed, with the airspeed trend vector (displaying predicted speed on the primary flight display) likely indicating well above the maximum operating speed (VMO) of the aircraft of 250 kt.
No kidding Sherlock - wind aloft + 20 - ATIS 5 knots - rate of descent monitored to compensate for anticipated conditions. No? Then we have a command problem, a training problem, an education problem and an attitude problem, not to mention over reliance and a dependency on a dumb machine. But, no matter.
ATSB - "The captain took hold of the controls and made nose-up pitch control inputs without immediately following the specified take-over procedure and alerting the first officer of his intent." - See above.
And so, a safeguard becomes a liability; at high speed subject to rough handling - and, predictably, it broke. Busted; but tough enough to get the aircraft back to Earth in one piece. Severely 'Grounded' one would hope - tea and biscuits with the CP to follow. Enforced by CASA and ATSB. Nope; a quick wipe over with an oily rag, and off the crippled airframe trots to complete a further 15 sectors. It is remarkable that not one pilot realised that the airframe flew cock-eyed - the AP just compensated while they played at being pilots. 15 sectors and not one pre-flight inspection noted that the tail plane was twisted? Unbelievable - and investigation discontinued - (expletive deleted)...
Yet, 'tis true. Both ATSB and CASA have decided to 'discontinue' the investigation on the flimsiest of excuses. There are deep, across the board systemic and operational aspects to this incident. That no one was killed is just dumb luck; the fundamental problems much deeper than the glib, slip-shod response from the very expensive 'safety' agencies.
Disgraceful; yet this band of Mutts parade, prance and preen as 'the' doyens of public safety in all matters aeronautical - Bollocks...
Toot - toot.
Towards the middle of the P2 post - HERE - you will find a short paragraph - which is the beginning of a bread crumb trail. It is an interesting trail to those genuinely interested 'real' safety matters, rather than the legal/political aspects of accident investigation and reporting. The links provided take you on an 'interesting' journey through the twisted pathways leading to the 'nothing to see - move along' Jedi mind trick. But there is much to see, non of it worth the cost..
P2 - "This brings me to the safety issues section of the FR and in particular under the heading of 'Regulatory surveillance – scoping of surveillance events"....
Snipe and counter snipe artfully disguised to cover over the indolence, arrogance and ineptitude of two very expensive 'safety' authorities. Masters of disingenuous obfuscation and good old fashioned arse covering.
ATSB. - "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 on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator".
Discontinued; time, money and effort wasted with no positive reporting aimed toward preventing similar 'attitudes' toward 'how' a company should operate etc. No useful stuff like redefining 'command' prerogative and authority. Not even a mention of the piss poor descent planning and monitoring leading to a panic induced lack of cockpit discipline. One could (ATSB should) strip the ATR event back to company culture, aircrew selection and training: and, management 'requirements' on the crew. There is food for thought there, but now, beyond the ambit of ATSB discussion or interest. 'Nuff said..
For us, it's time to pay a visit to the flight deck. We can start a few minutes before Top of Descent;
ATSB - "As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, 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". (abuse of language).
Clearance and ATIS noted, briefing complete; power back and, down we go - standard rate; a tick short of 'red line' speed, which is unwise, as we discover.
"While passing through about 8,500 ft, the aircraft encountered a significant windshear that resulted in a rapidly decreasing tailwind". Bollocks; try the inversion on for size. WTD has a 'rapidly decreasing tail wind got to do with it; rubbish! Ground speed :: Airspeed? Ring any bells?
"This led to a rapid (15 small knots?) increase in airspeed, with the airspeed trend vector (displaying predicted speed on the primary flight display) likely indicating well above the maximum operating speed (VMO) of the aircraft of 250 kt.
No kidding Sherlock - wind aloft + 20 - ATIS 5 knots - rate of descent monitored to compensate for anticipated conditions. No? Then we have a command problem, a training problem, an education problem and an attitude problem, not to mention over reliance and a dependency on a dumb machine. But, no matter.
ATSB - "The captain took hold of the controls and made nose-up pitch control inputs without immediately following the specified take-over procedure and alerting the first officer of his intent." - See above.
And so, a safeguard becomes a liability; at high speed subject to rough handling - and, predictably, it broke. Busted; but tough enough to get the aircraft back to Earth in one piece. Severely 'Grounded' one would hope - tea and biscuits with the CP to follow. Enforced by CASA and ATSB. Nope; a quick wipe over with an oily rag, and off the crippled airframe trots to complete a further 15 sectors. It is remarkable that not one pilot realised that the airframe flew cock-eyed - the AP just compensated while they played at being pilots. 15 sectors and not one pre-flight inspection noted that the tail plane was twisted? Unbelievable - and investigation discontinued - (expletive deleted)...
Yet, 'tis true. Both ATSB and CASA have decided to 'discontinue' the investigation on the flimsiest of excuses. There are deep, across the board systemic and operational aspects to this incident. That no one was killed is just dumb luck; the fundamental problems much deeper than the glib, slip-shod response from the very expensive 'safety' agencies.
Disgraceful; yet this band of Mutts parade, prance and preen as 'the' doyens of public safety in all matters aeronautical - Bollocks...
Toot - toot.