[Peetwo]

Proof of Popinjay obfuscation of Safety Issues and Recommendations - WTD??

Courtesy of the NTSB:

Safety Recommendations

The NTSB issues safety recommendations to address specific safety concerns uncovered during investigations and to specify actions to help prevent similar accidents from occurring in the future. Safety recommendations are our most important product because they alert government, industry, and the public to the critical changes that are needed to prevent transportation accidents and crashes, reduce injuries, and save lives.

We:

• issue recommendations to the organizations best able to take corrective action, such as the US DOT and its modal administrations, the Coast Guard, other federal and state agencies, manufacturers, operators, labor unions, and industry and trade organizations.
  
• issue safety recommendations at any point during the investigation of transportation accidents and in connection with safety studies.
  
• monitor the progress of action to implement each recommendation until it is closed, which usually takes several years.
  

Courtesy the TSBC:

Recommendations

As part of its mandate, the TSB makes recommendations to eliminate or reduce safety deficiencies that pose significant risks to the transportation system and warrant the attention of regulators and industry.

Under the Canadian Transportation Accident Investigation and Safety Board Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies. The Act does not require other stakeholders to respond to the TSB's recommendations, but they usually do.

Using the Assessment rating guide, the Board assesses responses to recommendations according to the extent to which the safety deficiency has been or is being addressed. Once the responses have been assessed as Fully Satisfactory, the recommendations are closed. The TSB continually monitors the progress being made on its recommendations.

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Air transportation safety letters and concerns

Safety concerns

Safety concerns provide a marker to the industry and the regulator that the Board has identified a safety deficiency for which it does not yet have sufficient information to make a recommendation. As more data and analysis become available, and if the safety deficiency is found to be systemic and not redressed, the safety concern may lead to a recommendation. Safety concerns are usually communicated in final investigation reports.

Safety information letters

The TSB sends safety information letters to regulatory and/or industry stakeholders to advise them of potentially unsafe acts or conditions identified during an investigation that pose low risks and do not require immediate remedial action. The letters aim to promote safety or clarify issues that a stakeholder is already examining, and are sent before the investigation has been completed. Those that do not contain privileged or proprietary information are posted here.

Safety advisory letters

Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and are used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety.

Spot the difference?? Via Popinjay HQ:

Safety issue: a safety factor that:

a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

Safety action: the steps taken or proposed to be taken by a person, organisation or agency in response to a safety issue.

Safety recommendation: a formal safety recommendation made either during or at the end of an investigation, where the ATSB remains concerned that a safety issue has yet to be adequately addressed by the relevant organisation.

Remember that in the course of the infamous 1st ATSB PelAir ditching investigation (and the subsequent Senate AAI Inquiry Report - now dead, buried and cremated), beyond all sensible Reason it was discovered that the ATSB initially identified a 'critical safety issue' that after much pushback from CASA was eventually downgraded to a minor safety issue...

From PAIN Supplementary submission: https://auntypru.com/wp-content/uploads/...lement.pdf



Since that time 'critical safety issues' still get a passing mention in all investigation updates, prelim, interim reports and even in Popinjay's bollocks non-interactive media releases.

Via Mornington Peninsula News:

“A final report will be released at the conclusion of the investigation, but if we identify a critical safety issue during the course of the investigation, we will immediately notify relevant parties so appropriate and timely safety action can be taken.”

The ATSB used to have definitions for the different safety issue categories but apparently no longer. So who is it that now defines whether a safety issue is in fact critical?

Trying to join the dots, I referred to the ATSB Aviation 'safety issues and actions' database webpages. This only led to further bemusement because according to that page (which I presume is in chronological order?) the last entry date for a safety issue is for 26/10/2023. However we all know there has been numerous safety issues issued in association with several investigation reports since.

In particular the following, which ended up with Popinjay issuing a SR to CASA: (Reference:  Popinjay v Su_Spence; closing safety loops?? - Let's do the timewarp again!)

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:

Quote: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.

In addition to that SI/SR there was four others issued: 

 AO-2022-016-SI-01 - Operator proficiency check requirements

AO-2022-016-SI-02 - Inadvertent instrument meteorological conditions recovery procedure and training


AO-2022-016-SI-03 - Pre-flight risk assessment

AO-2022-016-SI-04 - Risk management of inadvertent instrument meteorological conditions

It is interesting to note that none of those SIs, including the SR, have an issue date. In fact I believe that no safety issues published in any aviation investigation final report, since 26/10/23??

However there is some chronological evidence of when the above safety issues were at least acknowledged and began to be actioned by the addressees:

Action description[b]

On [b]6 April 2023, Microflite advised the ATSB that they had reviewed their operator proficiency check for their day visual flight rules (VFR) pilots and added knowledge and practical skills checks for avoiding and recovering from inadvertent entry into instrument meteorological conditions (IMC).

On 21 November 2023, Microflite advised the ATSB that:

Microflite does not intend to mandate training for inadvertent entry into IMC for all Day VFR Pilots in unstabilised single-engine VFR helicopters. While the potential benefits of such a policy are understood, introducing this requirement for all pilots is impractical and uncommercial, as:

a. such training is not required by the current regulations;
b. the perishable nature of this training means that one-off licencing/training is insufficient – annual training and regular competency checks are required; and
c. there is an insufficient number of instrument-rated instructors and aircraft available to service the single-engine Day VFR environment.

Microflite will (in excess of its regulatory obligations) implement such training where appropriate and will continue to emphasise ICARUS device training and improved decision making for pilots (including non-IFR pilots) who operate these aircraft.

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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.

Hmm...much more to follow me thinks?? 

P2