[Peetwo]

AO-2022-058 FR: Popinjay to the rescue issues SRs - WTD?

Remember this post from the top of the page (pg 17)? - Proof of ATSB delays and ICAO Annex 13 non-compliance??  

Well kudos to PJ's crew having completed yet another investigation off that list within one year (345 days)??   

At the same time they have issued two (very rare) safety recommendations, both addressed to the operator?? 

The (attributable to) PJ 'bollocks' presser:

Safety recommendations issued after Saab 340 taxied for flight with horizontal stabiliser bung not removed



The Australian Transport Safety Bureau has issued two safety recommendations following an incident where a horizontal stabiliser bung was not removed from a Saab 340 regional airliner prior to taxi at Cairns Airport.

On 16 November 2022, the Regional Express operated Saab 340B was taxiing for take-off from Cairns for a scheduled passenger flight to Bamaga, Queensland, when an engineer on a nearby parking bay noticed something hanging from the aircraft, and contacted the tower.

The air traffic controller visually confirmed the engineer’s observation and alerted the crew, who returned the aircraft to the bay.

“To prevent bird nesting, the operator required its aircraft parked overnight in Cairns to be fitted with a bung installed in each of the two horizontal stabiliser trim actuator coves,” ATSB Chief Commissioner Angus Mitchell said.

At interview, no members of the ground crew and flight crew involved in the pre-flight checks recalled seeing either of the bungs installed, nor the tether which connects the two, which has a ‘remove before flight’ conspicuity flag in the middle.

An inspection conducted once the aircraft returned to the bay identified the bung was still installed in the left trim actuator cove, with the rest of the bung assembly hanging from it.

“The horizontal stabiliser bungs were most likely incorrectly installed – or possibly the tether rope with the ‘remove before flight’ flag was not hanging from the horizontal stabiliser as designed – resulting in them not being detected during pre-flight preparations and the aircraft being dispatched with the bung installed,” Mr Mitchell said.

“Targeted inspection of locations and components, rather than relying on flags which may not always be visible, can help identify when these covers or devices have not been removed.”

The ATSB’s investigation found the operator had no formal procedures for the storage and accountability of the bungs after they were removed from the aircraft.

It also found the design of the bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight. 

The investigation notes the operator has commenced a risk assessment to formalise the procedures around the use of the horizontal stabiliser bungs, and to support this, an engineering order was developed to document and approve the manufacture of the bungs.

“However, these actions do not address the issues around the storage and accountability of the bungs when they are removed or the aspects around the identification of an installed bung or the safe operation of the aircraft if the bungs were not removed,” Mr Mitchell noted. 

As such, the ATSB has issued Regional Express two safety recommendations and will continue to monitor the progress the operator takes in addressing these.

“When a missed item has the potential to affect the safety of a flight, a secondary means of assuring the item has been removed should be employed,” Mr Mitchell concluded.

“Similar to procedures employed for other covers on aircraft, a means to account for what equipment has been removed from the aircraft before being stowed or retained by ground agents will provide the crew with another opportunity to detect when a bung or cover has not been removed.”

Read the final report: Aircraft preparation event involving Saab 340B, VH-ZLJ, Cairns, Queensland on 16 November 2022

Publication Date 26/10/2023

WTD?? 

There is some bizarre disconnections with this whole (IMO) WOFTAM investigation. To begin here is the entry for the investigation from my 22 March post at the top of the page:  42. AO-2022-058 (Short)

So for at least 4 months this investigation was listed as 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.

IMO, with no injuries, fatalities or even damage to the aircraft,  even a short for this operational occurrence was overkill. If anything perhaps the issuing of an OB..

Occurrence briefs

Occurrence briefs provide the opportunity to share important safety messaging and information with industry and the public in the absence of an investigation. They are a short factual summary to detail the circumstances surrounding an occurrence, which only uses information gathered during the initial notification, and from any follow-up information with relevant parties.

Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information within them is de-identified. While they do not include any analysis, findings, safety issues, safety actions or recommendations, occurrence briefs do provide an additional opportunity to learn from the experiences of others.

Occurrence briefs can be produced by ATSB Transport Safety Investigators or members of our Safety Reporting Team (all of whom have significant transport industry experience).

...with the operator's consent and after reviewing the REX SMS investigation report and findings.

However sometime after the 22nd of March a decision was made to escalate the investigation to 'defined':

Defined investigations

Defined investigations look at transport safety accidents and incidents of a more complex nature than short investigations, and seek to identify systematic safety issues that reveal underlying causes of an occurrence. They involve several ATSB resources and may involve in-the-field activity or be an office-based investigation. Evidence collected can include recorded flight and event information, multiple interviews, analysis of similar occurrences, and a review of procedures and other risk controls related to the occurrence.

Defined investigation reports include an expanded analysis to support the broader set of findings within the report and may include safety factors not relating directly to the occurrence. Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. The report also identifies safety issues, along with proactive safety action taken by industry and ATSB safety recommendations.

 

 Perhaps the key here is the last line in bold? However that would suggest that the identified safety issues were only discovered at least some four months into the investigation, after 1st interviewing the flight crew and reviewing the operator/SMS actions/inactions etc.

Safety Issues

AO-2022-058-SI-01
No procedure for storage and accountability

AO-2022-058-SI-02
Horizontal stabiliser bung design considerations

This brings me to the next aberrations with this bizarre investigation report. After reading through the FR there doesn't appear to be one reference to the REX SMS, instead we get this blurb about safety risk mitigation:

Risk assessment

While a risk assessment of the bird nesting hazard led to the implementation of the procedure to install the horizontal stabiliser bungs, the operator did not conduct a separate risk analysis of the potential hazard a control surface bung could induce. Although the design incorporated features to aid in the recognition of the bungs when they were installed correctly, the evidence indicated that the design allowed for an incorrectly installed bung or one not displaying as designed to go undetected.

Existing procedural checks designed to detect fouled or jammed controls did not identify the incorrectly installed bung and there was no documented consideration given to assuring that a bung would be ejected prior to take-off, after which time it could have had the potential to adversely affect the safety of a flight.

And this totally inappropriate opinion piece under the summary of 'what has been done as a result'

The operator has commenced a risk assessment to formalise the procedures around the use of the horizontal stabiliser bungs. To support this, an engineering order was obtained to document and approve the manufacture of the bungs.

However, these actions did not address the issues around the storage and accountability of the bungs when they are removed or the aspects around the identification of an installed bung or the safe operation of the aircraft if the bungs were not removed. As such, the ATSB issued two safety recommendations and will continue to monitor the safety issues and provide website updates.

Such risk assessments are (or should be) the primary function of the REX SMS? If this occurrence has not been effectively addressed (in an appropriate time) by the REX SMS, then I would suggest that is the real latent significant safety issue that should have been identified by Popinjay's crew...

The last point I would make is that those SRs were only issued to the operator yesterday:

Date issue released 26/10/2023

Safety Issue Description

There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.

---

Date issue released 26/10/2023

Safety Issue Description

The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.

WTD? 

MTF...P2