[Peetwo]

Popinjay to the rescue - yet again?? 

In follow up to above, the prelim report was 56 days in non-compliance with ICAO Annex 13: 

Under Annex 13 to the Chicago Convention, States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

  
Here is the bollocks media blurb with video and "attributable to" Popinjay narration included -  :

ATSB preliminary report details 737 large air tanker accident sequence of events

Key points

• 737 had been tasked to tag and extend a line of fire retardant which extended downslope;
  
• Flight data and cockpit voice recorder downloads instrumental in establishing accident sequence of events;
  
• Preliminary report outlines factual information collected in the on-going investigation’s early evidence collection phase.
  

An ATSB preliminary report details the sequence of events leading to a Boeing 737 large air tanker’s impact with a ridgeline in Western Australia’s Fitzgerald River National Park while conducting an aerial fire-fighting task on 6 February 2023.

The preliminary report outlines factual information collected in the on-going investigation’s early evidence collection phase, and details that the modified Coulson Aviation-operated 737 air tanker, callsign ‘Bomber 139’, with two pilots on board, had departed from Busselton Airport to assist fire control efforts near Hopetoun, about 600 km south-east of Perth.

“Arriving at the fire ground, the 737 crew was briefed by a bird-dog aircraft that the tasking was to tag and extend an existing retardant line,” said ATSB Chief Commissioner Angus Mitchell.

“The retardant line was to extend downslope, with the bird-dog briefing the 737 crew that their target altitude (above sea level) was 500 feet descending to 400 feet.”

Flight recorder data shows that Bomber 139 descended to about 400 ft and completed a partial drop of three-quarters of their tank before the captain, who was pilot flying, stopped the drop because their retardant line was entering a burnt area.

Bomber 139 then repositioned to commence another drop to use the remaining retardant to further extend the retardant line.

During the second drop, Bomber 139 descended through 400 ft altitude – or 80 ft above ground height – at an airspeed of 110 kt with the engines at high idle as the retardant line was extended downslope.

“Flight recorder data shows the throttles were advanced and the engines had accelerated just before the aircraft struck a ridgeline with the stick shaker activating. The aircraft then cleared a small line of foliage, before impacting the ground a second time and sliding to rest,” said Mr Mitchell.

“Fortunately, and remarkably, both pilots were able to exit the aircraft through a cockpit window, and suffered only minor injuries.”

The aircraft was subsequently consumed in a post-impact fire.

“Despite extensive fire damage, ATSB recorders specialists in our Canberra technical facilities were able to download files from both the flight data recorder and cockpit voice recorder,” Mr Mitchell said.

“As well as information from those recorders, interviews with the flight crews, a 3D map of the accident site created using a drone, and other recorded flight information will be instrumental to the ongoing investigation.”

ATSB investigators have also collected documents and recorded data from the operator as well as records from the WA Department of Fire and Emergency Services.

“The investigation is continuing and will include validation of the recorded data and reviews of the communication procedures for bird-dog and large air tanker pilots, the operator’s crew resource management procedures and practices, and standards and safety margins for 737 retardant drops.”

The preliminary report notes that following the accident, the operator increased their large air tanker minimum retardant drop heights and airspeeds.

Mr Mitchell said that a final report, containing findings and the analysis to support those findings, will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the report: Collision with terrain involving Boeing Company 737-3H4, N619SW, Fitzgerald River National Park, Western Australia, on 6 February 2023

Publication Date
03/05/2023

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Safety action

Following the accident, Coulson Aviation issued operations bulletin 2023-01 advising their large air tanker pilots operating in Australia that their minimum retardant drop heights and VDROP airspeeds had been increased from 150 ft above ground level and 1.25 VS to 200 ft above ground level and 1.35 VS. Their B-737 normal checklist was amended accordingly to reflect their new minimum VDROP airspeeds.

Hmm...a prelim report is supposed to be a short factual statement, with initial safety issues possibly identified, followed by where the investigation will be focused going forward. IMO this prelim report is a lot more than that and I will be surprised, other than a bit more content, how much the final findings (probably in about 4 years time) and the context of this prelim report will change when the final report is published - verdict save the dosh and either hand over this investigation to the NTSB to complete; or complete to final report in world record time inside of 6 months (there's a challenge for you Popinjay -  )...

Subject next - over to this week's Director Transport Safety Stewie Macleod -  :

Lift-off location following a touch-and-go is more variable and complex to predict than a standing take-off, investigation highlights

Key points

• Aircraft collided with rising terrain after conducting a touch and go from a rural property airstrip during a preparation flight for a commercial pilot licence test;
  
• Preflight planning was likely not performed to identify if the airstrip was suitable for flight training operations;
  
• Touch-and-go likely used more runway than a standing take-off, leading to the aircraft becoming airborne further along the runway, and closer to the rising terrain.
  

Rising terrain in the direction of take-off meant an airstrip being used for a touch-and-go was unsuitable as it exceeded the climb performance of the aircraft, an Australian Transport Safety Bureau investigation has found.

Two pilots, an instructor and student, were fatally injured when their single-engine two-seat Aquila aircraft collided with an embankment after a touch-and-go at Coombing Park airstrip in central west New South Wales, on 4 November 2020.

The flight was being conducted to assess the readiness of the student to complete a commercial pilot licence flight test. The flight had proceeded to overhead Coombing Park, where the student demonstrated the conduct of a precautionary search, to assess the suitability of conducting a landing there.

Following the precautionary search, a touch‑and‑go (landing without coming to a stop and accelerating to take-off again) was performed at Coombing Park. As the aircraft climbed through 200 ft above the lift-off point, a climbing left turn was conducted before flying straight again in the direction of a small dam, beyond which was a less wooded area. The aircraft then passed over the small dam and collided with an embankment on the far side of the dam.

“The ATSB found that pre-flight planning was likely not performed to identify if Coombing Park was suitable for flight training operations, which placed more importance on the conduct of the precautionary search to identify the rising terrain hazard in the overshoot area of the runway,” said ATSB Director Transport Safety Stuart Macleod.

“The precautionary search was conducted at a height and position that likely made assessing the hazard less effective.”

Further, the take-off was conducted on an uphill slope with a probable tailwind. A standing take-off in the more favourable reciprocal direction would likely have cleared all obstacles and terrain.

“Particularly at an unfamiliar airstrip, pilots must carefully consider the aerodrome characteristics to confirm if a touch-and-go is feasible, or if a full-stop landing and standing take-off should be completed instead,” Mr Macleod said.

“This accident demonstrates that the lift-off location following a touch-and-go is more variable and complex to predict than a standing take-off.”

The investigation also found that the aircraft operator had based its operations manual on the sample operations manual published by the Civil Aviation Safety Authority (CASA), which allowed for flight training into any aerodrome listed in the En-Route Supplement Australia (ERSA), including ALAs, although ALAs are not assured to any operational standard.

In addition, the investigation found that recommendations contained in the since-replaced CASA guidance CAAP 92-1(1) did not provide assurance that an aircraft would be able to outclimb rising terrain after take-off more than 900 metres from the runway end.

“Operators should also be aware that aerodromes meeting the recommendations in the now-obsolete CASA guidance publication CAAP 92-1(1) are not assured that an aircraft will be able to successfully climb away after take-off more than 900 metres past the runway end,” said Mr Macleod.

“The new performance-based recommendations of AC 91-02 now require operators to consider obstacle clearance beyond 900 metres.”

Flight training operators should also note that there are no standards for ALAs, even those listed in the ERSA as uncertified aerodromes.

“The published data, including obstacle information, for these uncertified aerodromes are potentially incomplete or inaccurate,” said Mr Macleod.

“This means that for take-off from ALAs, the new guidance requires pilots and operators to know the climb gradient needed to clear all obstacles by a safe margin until the aeroplane reaches the minimum height for flight,” Mr Macleod concluded.

Read the report: AO-2020-059: Collision with terrain involving Aquila AT01, VH-OIS, Coombing Park Airstrip, 27 km south of Orange, New South Wales on 4 November 2020

Publication Date 04/05/2023

     
Hmm...64 pages of?? - Don't even know where to begin with this one...

MTF...P2