[Peetwo]

Popinjay v Su_Spence; closing safety loops?? - Let's do the timewarp again!

Remember this?

That was from Budget Estimates nearly 12 years ago and signifies the start of Senator Fawcett's concern ('closing safety loops') for a lack of proactive action by Government departments and agencies (responsible for the oversight of the aviation industry and aviation safety) in response to safety recommendations addressed to them by both the ATSB and State Coroners.

The example he used came from a PAIN_Net document called 'Coronial analysis':





DF followed up his questioning of Murky Mrdak on 'closing safety loops' in the 2012 Supplementary Estimates, which ironically was held a week before the infamous (now forgotten) Senate AAI (PelAir) inquiry began:

FFWD 7 years to this Ferryman 'Closing the safety loop - Coroners, ATSB & CASA' thread post..

Safety Loop or Hangman’s noose?

Cheers P2; this has been coming for a while now and is well over due. Sen. Fawcett tried to get the ball rolling in the right direction way back in 2012, yet seven years later the core subject matter has not been properly addressed in a positive or even a satisfactory fashion.

We did do an abridged version of the analysis we ran – HERE – but – as I recall we left it on the shelf after while when the promised legislation and amendments failed to materialise (as per usual). There is a long list of them; and all that seems to have surfaced is more ways to allocate blame, but little in the way of ‘preventing’ a reoccurrence. The same ‘accident’ has been claiming lives for quite a while, clearly demonstrating that ‘rules’, no matter how complex, simply are not preventing repeat accidents.

16/10/2012 - Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Fawcett, with a flick of his wrist has unveiled the Elephant in the room. It is a simple concept which, IMO the departments involved have been at some pains to avoid acknowledging. The construct is a simple one:- (a) there has been a fatal; (b) ATSB have, best they may defined the nature of it; © there is a Coroners court; (d) the Coroner makes recommendations and hands down his findings; (e) nothing further happens – in real terms.

ATSB sit on their hands: they have put forward their recommendations.
Coroner moves on to the next case – job done.
CASA adopt their standard plan, dismiss recommendation as opinion, tell the ATSB to bugger off and life rolls on as though nothing happened; except the liability and ‘blame’ game continues unabated.

Visual flight into instrument conditions is an old killer. There are remedies, but for every remedy the is a stone wall built to prevent CASA from making the commitment to change. The Private IFR rating – graduated approval – all too hard for CASA – they may have to answer questions. It is easier to say NO than it is to expose the lack of operational safety expertise needed to make such a scheme a winner.

Flight in Night Visual conditions is another area which has claimed many lives. It is not inherently dangerous, but it is an operational flight discipline which demands care and  training. Experienced pilots as well new chums get into strife as the data shows. Once again remedies are available; once again CASA needs the sorely lacking imagination and operational experience to apply a cure.

The damn shame is that there is, within industry, a wealth of operational and technical expertise which CASA could call on to assist develop ‘ways and means’. Alas, even Senate Committee and independent report recommendations are dismissed as merely the ‘opinions’ of the Ills of Society; or, of folk who don’t understand that the mystique of aviation safety is worth squillions to those who frequent the CASA top table trough.

We are in desperate need of a Minister who is not captured, hypnotised or baffled by the mystique and unconcerned about the blood being on ministerial hands. Fat chance – right.

Toot – toot.

And on the subject of ATSB issuing safety recommendations addressed to CASA, PAIN did an opinion piece in 2015 which included a statistical comparison to the 'Gold Standard' NTSB:







Now FFWD to last week, when Popinjay was attributed to yet another bollocks media release for the release of the final report into the AO-2022-016 systemic investigation:

Effective risk management of inadvertent entry into IMC relies on multiple layers of controls, ATSB Mt Disappointment investigation highlights

The ATSB investigation into an Airbus EC130 helicopter accident on Mount Disappointment highlights that the effective management of the risk of inadvertent entry into instrument meteorological conditions (IMC) relies on multiple layers of controls.

The helicopter was one of two EC130s, operated by Microflite, which had departed a helipad at Melbourne’s Batman Park bound for Ulupna in Victoria’s north, on 31 March 2022. The pilots of both helicopters were operating under the visual flight rules (VFR) – regulations that permit a pilot to operate an aircraft only in weather conditions clear enough to allow the pilot to see where the aircraft is going – but had planned and commenced a route for which instrument meteorological conditions were present.

The pilots continued the flight as conditions deteriorated until a rapid change of course was required to avoid entering cloud.

“During the attempted U-turn without visual cues the second helicopter developed a high rate of descent, resulting in the collision with terrain,” said ATSB Chief Commissioner Angus Mitchell.

“Unfortunately, the pilot had no instrument flying experience, and the helicopter was not equipped with any form of artificial stabilisation, albeit neither of which are required for VFR flying.”

All five occupants of the helicopter were fatally injured in the accident.

Mr Mitchell noted that whilst not required by regulations the helicopter operator had not incorporated several available risk controls for their day VFR pilots to mitigate against inadvertent entry into IMC.

“These risk controls may have included inadvertent IMC recovery training and basic instrument flying competency checks during operator proficiency checks.”

The operator had also not introduced an inadvertent IMC recovery procedure for their air transport operations, or a pre-flight risk assessment to trigger an escalation process for marginal weather conditions identified at the pre-flight planning stage.

The investigation report notes that the operator had identified poor weather conditions as a risk, but its management of that risk was limited to the mandated regulatory requirements, and it did not consider ways to enhance pilot recovery from an inadvertent IMC event.

The Civil Aviation Safety Regulations for rotorcraft air transport (Part 133) only require the risk of a VFR inadvertent IMC event to be managed through avoidance.

“While avoidance of inadvertent IMC is important, it is not always assured, and Part 133 does not address the risk of recovery from an inadvertent IMC entry event.”

Mr Mitchell said the ATSB encourages all pilots to develop the knowledge and skills required to manage the risk of inadvertent IMC.

“Decision-making in marginal weather conditions can be supported with the use of a pre-flight risk assessment tool,” he said.

At an organisational level, the risk of helicopter inadvertent IMC should be considered within the context of a company’s operations.

“The effective management of this risk relies on multiple layers of controls to reduce the risk of single point-of-failure accidents.”

This includes training and procedures for both avoidance and recovery, which can be enhanced with equipment, such as autopilots to reduce the risk of loss of control, and terrain awareness and warning systems to reduce the risk of controlled flight into terrain.

Mr Mitchell acknowledged the operator had taken a number of actions as a result of the accident including introducing basic instrument flying training and inadvertent IMC recovery training; updating their proficiency check syllabus to include knowledge and practical skills checks for avoiding and recovering from inadvertent IMC; and upgrading the avionics systems on its helicopter fleet to incorporate synthetic vision, a terrain alerting functionality, and, where available, an autopilot.

The ATSB has also recommended that CASA take further safety action to address the risk of inadvertent IMC events in Part 133 helicopter passenger operations.

Read the report: VFR into IMC, loss of control and collision with terrain involving Airbus Helicopters EC130 T2, VH-XWD, near Mount Disappointment, Victoria, on 31 March 2022

It is interesting to note that this 'systemic investigation' was completed in an almost world record time (for Popinjay) of 1 year 9 months and 11 days. It included a prelim report that took approximately 6 weeks to complete and bizarrely 5 (publicly unannounced) updates, which didn't include an interim report on the anniversary date (ICAO Annex 13 para 6.6):  

Updated 4 December 2023 (PS: Rumour has it that Popinjay had an extraordinary management meeting on the same day??)

The external review phase has been completed and the draft report has been updated to a final report. The final report is now under internal review prior to publication.

Updated 24 October 2023

The draft investigation report has been distributed to the directly-involved-parties for external review.

Updated 17 July 2023

The investigation report has been drafted and is now under internal review before distribution to the external directly-involved-parties.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken. A final report will be released at the conclusion of the investigation.

Updated 16 June 2023

The ATSB has completed the analysis phase and the investigation has progressed to the report drafting phase.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken. A final report will be released at the conclusion of the investigation.

Updated 2 December 2022

The ATSB has successfully retrieved 1-second flightpath data from the pilot’s electronic flight bag (iPad) and downloaded the helicopter’s vehicle and engine multi-function display and Appareo camera, which contained a recording of the accident flight. The engine electronic control unit, which was severely fire damaged, and Garmin GTN750 global positioning system were not downloaded as it was considered unlikely that they would provide additional information about the operation of the helicopter or the accident sequence.

Further investigation

To date, the ATSB has examined and analysed the accident site and wreckage, pilot qualifications and training, medical records for the occupants, vehicle recorded data, meteorological data from the Bureau of Meteorology, interviews and statements, and flight planning and maintenance data. The ATSB will continue to liaise with Victoria Police, and the French Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) as the accredited representative for the helicopter and engine manufacturers.

The investigation is continuing and will include the review and analysis of the operator’s risk controls and similar occurrences.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

I say bizarrely because the updates are pretty much outlining the fundamental stages (progress) of any ATSB systemic investigation - see HERE. 

IMO what is standout for this investigation is the correspondence/responses in reply to the ATSB's issuing a SI (safety issue) to CASA, that was ultimately escalated to a SR (safety recommendation) with the release of the final report (note that the SI refers to deficiencies in CASR Part 133, which was originally released for industry consultation 24 years ago)...

Action description

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to further address the risk to rotorcraft air transport (Part 133) passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.

Organisation Response
Organisation Civil Aviation Safety Authority

Response Text

On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:

This safety issue is misconceived as it does not consider the safety management potential of the combined air transport regulatory suite.

It also relies, as does the report, entirely on the context of needing to add either additional equipment (instrumentation), additional systems (SAS, autopilots) and additional flight crew training (instrument flight training) and flight crew recency (IF recency), as the solution to IIMC events.

Whilst these may offer some assistance, they are in most instances reactive, after IIMC has occurred, and are expensive fixes, which notably, the industry has already rejected.

CASA recommends the safety issue is withdrawn for the reasons outlined in this overall feedback and substituted with an action to include further guidance material on IIMC within the AMC/GM for Part 133 of CASR. As is the case with EASA and transport Canada, noting transport Canada’s material is primarily associated with “white out condition IIMC” which is a very rare event in Australia.

CASA also notes the numerous articles it has already published on VFR into IMC in its Flight Safety magazine on this issue.

"CASA recommends the safety issue is withdrawn" - 

(Note the date of the CASA response is a day after the release of Popinjay's cover up Croc-O-Shite report -  )

Hmm...I've seen plenty of CASA pushback on ATSB safety issues addressed to them but I believe this is a 1st where the regulator 'recommends' they withdraw the SI??

The Popinjay response is equally remarkable and leads to the ultimate issuing of an SR to CASA:

ATSB Response

Throughout the course of this investigation, the ATSB found numerous optional VFR into IMC risk controls available to the operator that were not mandated for their day VFR pilots. This was explained in the safety analysis and has extended to the operator’s responses to the safety issues, citing the provision of training outside the regulatory requirements as impractical and uncommercial. Performance-based approaches to safety should complement prescriptive approaches and not replace them as it can lead to the treatment of safety requirements as ‘optional’ and may result in competitive advantages to operators with lower safety standards. Performance-based approaches should also be responsive to outcomes, such as accidents, so that safety requirements can be adjusted to meet the acceptable level of safety.

While equipment, systems and training will greatly improve the chances of recovering from a VFR into IMC event, this is not the extent of the ATSB’s report, which has also discussed operational information, organisational information, research studies of VFR into IMC and intervention strategies, including avoidance and recovery. The ATSB report also acknowledges the cost of the autopilot system for the EC130 helicopter and the helicopter industry's opposition to basic instrument flying training, which was a majority but not a consensus.

The ATSB acknowledges the work done by CASA to develop and deliver flight planning and weather assessment educational material, safety seminars and guidance material, which included the ‘Don’t push it, land it | Flight Safety Australia’ campaign for helicopter pilots to make the decision to land when confronted with deteriorating weather. However, the ‘Don’t push it, land it’ strategy is only applicable to helicopters operating underneath the cloud base and is not applicable to ‘VFR over the top’. In this accident, the pilots proceeded ‘VFR over the top’ before the VFR into IMC event.

The Australian National Aviation Safety Plan 2021-2023, to which the ATSB and CASA were contributing agencies, stated Australia’s acceptable level of safety performance included:

No accidents involving commercial air transport that result in serious injuries or fatalities, no serious injuries or fatalities to third parties as a result of aviation activities and improving safety performance across all sectors.

Therefore, any risk assessment of a fatal commercial air transport accident by CASA should be consistent with Australia’s stated acceptable level of safety performance. To progress towards this level of safety, CASA need to capture lessons learned from fatal accidents in Australia in the Australian aviation standards.

In addition to this accident, the ATSB has recently investigated a fatal VFR into IMC accident in Tasmania, AO-2018-078, by a commercial aeroplane pilot en route to collect passengers, a fatal VFR into IMC Part 135 (Australian Air Transport Operations—smaller aeroplanes) accident in Queensland, AO-2022-041, and is currently investigating a fatal Part 135 accident involving adverse weather in the Northern Territory, AO-2022-067. As CASA has not committed to taking safety action in response to this safety issue, the ATSB is issuing a safety recommendation.

 
The reference in bold to the NASP (and the ATSB , CASA as contributing agencies) is intriguing and perhaps shows a naivety of Popinjay that the other 'contributing agencies' and Dept actually believe the NASP is anything more than words on a page and a placation to compliance to ICAO Annex 19 - 

4.2 Acceptable level of safety performance

Each safety goal contributes to an overall acceptable level of safety performance for Australia.
Australia’s acceptable level of safety performance, or the sum output of Australia’s safety goals, is:

No accidents involving commercial air transport that result in serious injuries or fatalities, no
serious injuries or fatalities to third parties as a result of aviation activities and improving safety
performance across all sectors.

(Ref: Pg 16)

Also refer to Appendix A (pg 26):

Safety Enhancement
Initiative - Mitigate contributing factors to Controlled Flight into Terrain.

&..

(pg 28):

Safety Enhancement
Initiative - Mitigate contributing factors to Mid-Air Collision accidents and incidents.

Hmm...and how's that working out?? 

The reference to 'Australian Aviation Standards' is equally intriguing because shouldn't that be - 'ICAO international aviation safety standards' (SARPs)?? 

Hmm...much, much MTF on this one - P2