[Peetwo]

PPR (Popinjay Performance Review): One from the list - 26. AO-2022-033 (Short)??

Ref:

The current clusterduck that is the ATSB: Part II

"..continues to work towards achieving its new performance measures established in the 2020-21 Corporate Plan..."

Refer to pages 12 to 14 here: https://www.atsb.gov.au/sites/default/fi...020-21.pdf

Where to start with all these bollocks statements? - How about pg 11 (241) of the ATSB budgetary statement at KPI5:

KPI 5 – Median time to complete
investigations:
• Short investigations - 7 months
• Defined investigations - 14 months
• Systemic investigations - 20 months

---

Tracking towards 7 months
Tracking towards 14 months
Tracking towards 20 month

'Tracking'?? - Err really: Proof of ATSB delays and ICAO Annex 13 non-compliance??

1. AO-2020-043 (Short)
2. AO-2020-059 (Defined)
3. AO-2020-060 (Short)
4. AO-2021-004 (Short)
5. AO-2021-022 (Short)
6. AO-2021-017 (Short with preliminary report issued - WTF??)
7. AO-2021-035 (Short)
8. AO-2020-059 (Note: This is a 'Defined' investigation and did have an update 2 months after the accident but none since)
9. AO-2020-060 (Short)
10. AO-2021-004 (Short)
11. AO-2021-018 (Systemic)
12. AO-2021-022 (Short)
13. AO-2021-032 (Short with a preliminary report attached and a safety advisory notice issued)
14. AO-2021-035 (Short)
15. AO-2021-044 (Short)
16. AO-2021-043 (Short)
17. AO-2021-048 (Systemic)
18. AO-2021-047 (Defined)
19. AO-2022-007 (Defined)
20. AO-2022-010 (Defined)
21. AO-2022-012 (Defined)
22. AO-2022-019 (Defined that bizarrely did issue an interim report 7 months after the incident)
23. AO-2022-025 (Short)
24. AO-2022-030 (Short)
25. AO-2022-031 (Short)
26. AO-2022-033 (Short)
27. AO-2022-032 (Short with a preliminary issued)
28. AO-2022-035 (Short)
29. AO-2022-036 (Short)
30. AO-2022-038 (Short)
31. AO-2022-039 (Short)
32. AO-2022-040 (Short)
33. AO-2022-042 (Short)
34. AO-2022-046 (Short)
35. AO-2022-049 (Short)
36. AO-2022-050 (Short)
37. AO-2022-053 (Short)
38. AO-2022-054 (Short)
39. AO-2022-052 (Occurrence Investigation)
40. AO-2022-055 (Short)
41. AO-2022-056 (Short)
42. AO-2022-058 (Short)
43. AO-2022-060 (Short)
44. AO-2022-061 (Short)
45. AO-2022-063 (Short)
46. AO-2022-062 (Short)
47. AO-2022-059 (Short)
48. AO-2022-064 (Short)
49. AO-2022-065 (Short)
50. AO-2022-066 (Occurrence Investigation)
51. AO-2022-067 (Defined)
52. AO-2022-068 (Occurrence Investigation)
53. AO-2023-002 (Short - Past 30 day limit for preliminary report)
54. AO-2023-004 (Short - Past 30 day limit for preliminary report)
55. AO-2023-005 (Short - Past 30 day limit for preliminary report)
56. AO-2023-007 (Occurrence Investigation - Past 30 day limit for preliminary report)
57. AO-2023-008 (Systemic - Past 30 day limit for preliminary report)
58. AO-2023-009 (Short - Past 30 day limit for preliminary report)

Is there anyone who is actually going to hold Popinjay to account on reneging on honouring many of these so called non-performance indicators?? - 

The Popinjay definition of a short investigation:

Short investigations

Short investigations provide a summary and analysis of commonly occurring transport safety accidents and incidents. Investigation activity includes sourcing imagery and documentation of any transport vehicle damage and/or accident site, conducting interviews with involved parties, and the collection of documents such as procedures and internal investigations by manufacturers and operators.

Short investigation reports include a description of the sequence of events, limited contextual factual information, a short analysis, and findings. Findings include safety factors (the events and conditions that increased the risk of incident or accident happening) but only examine the actions and conditions directly relating to the occurrence and any proactive safety actions taken.

Surprise...surprise we actually have an example of a short investigation from the list above that has actually been completed -  : AO-2022-033

This non-event was strangely considered to have significant enough safety value to be accompanied by one of those bollocks media blurbs by this week's Director of Transport Safety Kerri Hughes...  

Contaminated pitot tubes before 737 freighter’s unreliable airspeed indications



Key points

• 737 freighter returned to Perth after flight crew observed discrepancy between altitude and airspeed on the pilot and co-pilot’s indicators.
  
• Investigation found that covers on the aircraft’s pitot-static probes had melted during maintenance.
  
• Although the probes were cleaned, residue was found on probes after flight.
  
• Incident highlights importance of maintaining high level of attention to damage and contamination when working on and inspecting these components.
  

The flight crew of a 737 freighter were presented with unreliable flight data information two days after the aircraft’s pitot probes were contaminated during maintenance, an ATSB investigation details.

The Airwork-operated Boeing 737 freighter, with four crew on board had departed Perth on 10 June 2022 for a freight service to Christmas Island, via Port Hedland.

As the aircraft was levelling off at 33,000 ft, the flight crew observed a 340 ft discrepancy between the altitude displayed on the captain’s altimeter, and the altitude on the first officer’s altimeter, which was connected to the autopilot.

The flight crew also observed discrepancies between airspeed and Mach numbers.

After descending to 30,000 ft and working through the relevant quick reference handbook, the flight crew established the first officer’s indications were reliable, and advised air traffic control of a need to return to Perth.

After an uneventful landing in Perth, ground crews found foreign residue adhered to the lower surfaces of all four of the aircraft’s pitot-static probes.

“The ATSB established that, during an engine ground run 2 days prior to the incident, the pitot‑static probe covers were not removed, and the automatic pitot heat was not isolated as required by the ground run procedures checklist,” said ATSB Director Transport Safety Kerri Hughes.

“As a result, the covers melted onto the probes. Although cleaned, residue remained on the probe surfaces, which had the potential to compromise the accuracy of the pitot-static instruments in-flight.”

However, as seven flights had been completed between the ground run and the incident flight with no altitude discrepancies reported during this time, the ATSB was unable to a establish a link between the remaining residue and the flight.

Irrespective, pitot probes are extremely sensitive to damage and disruption.

“Data received from an aircraft’s barometric air data sensing instrumentation components is critical for safe flight, and this incident highlights the importance of maintaining a high level of attention to damage and contamination when working on and inspecting these components.”

The ATSB report also notes the flight crew did not notify air traffic control of the altitude discrepancy of 340 ft.

“This discrepancy exceeded the 200 ft maximum allowed altimetry system error for the reduced vertical separation airspace in which they were operating,” Ms Hughes said.

“Flight crews need to advise air traffic control of altimetry system errors, so adequate vertical separation with other aircraft can be assured.”

Since the incident, the maintenance organisation has undertaken several procedural initiatives to reduce the likelihood of melted pitot-static probe covers in the future, including replacing the polyvinyl chloride covers with high temperature resistant Kevlar covers.

Read the report: AO-2022-033 - Unreliable altitude indications, Boeing 737-476SF, ZK-TLJ 167 km west of Meekatharra Airport, Western Australia on 10 June 2022

Publication Date
13/04/2023

 
Hmm...I'll let others more qualified than me make an assessment of the safety value of a report that IMO should have been ticked and flicked five minutes after arriving in the inbox of the desk jockey TSI assigned to this. Also, I guess that 10 months 3 days for completion is sort of tracking towards 7 months...   


MTF...P2 

PS: On the subject of 'Systemic' investigations tracking towards completion inside 20 months, I note that the ATSB has yet again gone past a promised update commitment for the YMEN DFO approval process systemic investigation: https://www.atsb.gov.au/publications/inv...i-2018-010

"..An update on timing for completion of the investigation will be provided at the start of 2023 after the ATSB has been able to complete necessary engagements with Australian and international DIPs..."