[Peetwo]

Popinjay continues to take the PISS on ICAO Annex 13 compliance - Part II

From the 2019 ANAO audit of the ATSB: "Efficiency of the Investigation of Transport Accidents and Safety Occurrences"

Read from CH 2 "Measuring and supporting operational efficiency":

Areas examined

The ANAO examined whether the ATSB had established efficient processes for the investigation of transport accidents and safety occurrences.

Conclusion

The ATSB has established key elements of an overall framework to promote efficient investigation processes. There is a focus on clearing the backlog of investigations that have been underway for some time, applying sound processes to decide which notifications merit a safety investigation, and adjusting key performance indicators to identify more realistic completion timeframes for the more complex investigations. The ATSB has also taken a number of actions to give greater attention to the efficiency with which it undertakes transport safety investigations.

Areas for improvement

The ANAO has made two recommendations. One relates to short investigations, where recent changed processes have had an adverse impact on completion timeframes.

The second encourages the ATSB to marry its increased focus on timeframe efficiency with greater attention to the resource efficiency of its investigations.

You will even find there is a reference to ICAO -  :

2.10 In October 2018, the ATSB advised the ANAO that the target of completing 90 per cent of complex investigations within 12 months was driven by the ATSB’s perspective as to what may be considered acceptable to industry and directly involved parties, including the next of kin. The ATSB further advised the ANAO that the 12 month target also took into account the International Civil Aviation Organization’s (ICAO) International Standards and Recommended Practices manual ‘Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Eleventh Edition, July 2016’ (Annex 13). Specifically, section 6.5 of Annex 13 states:

In the interest of accident prevention, the State conducting the investigation of an accident or incident shall make the Final Report publicly available as soon as possible, and if possible, within twelve months.

However for this post I am more interested the following recommendation for the completion of 'short' investigation:

Recommendation no.1

2.8 The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

2.9 The ATSB acknowledges the average increase in time taken to complete short investigations since 2016–17. The ATSB plans to address this issue through the allocation of dedicated investigator resources, within the current organisational structure, to short investigations.

Then refer to page 25 'Results against key performance criteria' table of Popinjay's 2022-23 Annual Report

Median time to complete investigations.

Target - Short 7 months/ Defined 14 months/ Systemic 20 months
Result - Short 10.4 months/ Defined 15.9 months/ Systemic 38.5 months

With all of the above in mind and in stiff competition, has Popinjay taken the record for the longest completion of a short investigation?

Last Wednesday the latest bollocks Media Release with Godlike attributed as the DTS was put out:

Diversion due to fuel imbalance and engine shutdown emphasises importance of checklist diligence



A Boeing 737’s crossfeed valve was not closed after a pre-flight fuel transfer, later resulting in a fuel imbalance warning which led to the flight crew unnecessarily shutting down one of the aircraft’s engines, an ATSB investigation report details.

Just after reaching cruise altitude on a Perth to Adelaide flight on 25 October 2021, the captain and first officer of a Qantas 737 were alerted to a fuel imbalance, indicating there were unequal quantities of fuel in the left and right main fuel tanks, located in each wing of the aircraft.

Prior to the flight, the captain had identified extensive cold soaked fuel frost on the wings, due to cold fuel remaining in the main tanks from the aircraft’s previous flight.

“To remedy this, the cold fuel was transferred to the centre tank, and the main tanks were refuelled with additional, warmer fuel,” ATSB Director Transport Safety Dr Stuart Godley said.

“The procedures required the crossfeed valve to be closed when the operation was completed, however, the valve was not closed. This was likely associated with the crew following the maintenance engineer’s verbal instructions rather than referring to the relevant procedure. While this is permissible, referring to procedures is a more reliable method to ensure all steps are carried out.”

During pre-flight checks, and later during the climb and level-off, the pilots did not notice the crossfeed selector in the open position, or the associated dimmed blue indicator light on the fuel panel.

Once the centre fuel tank was exhausted and its pumps were switched off, the open crossfeed valve allowed fuel to be continually pumped from the left main tank to the right engine, as a result of uneven fuel pump pressures.

While the aircraft’s manuals stated this could occur, the flight crew did not recall this, and the Boeing 737 imbalance checklist, worked through by the flight crew, did not provide sufficient guidance for an open crossfeed valve to be identified as the potential reason for a fuel imbalance.

“This led the flight crew to decide there could be a fuel leak and then, partly as a result of confirmation bias, stress and perceived time pressure as the aircraft approached the Great Australian Bight where it would fly over water, they abbreviated the relevant checklists and mistakenly confirmed a fuel leak as the cause for the imbalance.”

The ATSB’s report notes the flight crew, when working through the fuel engine leak checklist, inadvertently performed a step out of sequence, invalidating the process, and contributing to their conclusion that there was a fuel leak.

As a result of this incorrect confirmation, the flight crew unnecessarily shut down the aircraft’s left engine during flight.

After the flight crew diverted to Kalgoorlie and conducted a single-engine landing, a post-flight inspection revealed there was no fuel leak, and the fuel system was serviceable.

Dr Godley noted that, although the presence of information in the checklist about the effect of an open crossfeed valve probably would have led to a different outcome in this case, a fuel imbalance condition is itself usually a minor condition, and the ATSB considered the checklists adequate to address a more serious condition such as a fuel leak.

“This incident highlights the importance to all pilots of being precise when following checklists, especially when under stress,” Dr Godley said.

“Checklists are designed to minimise performance variability under workload and stress, increasing the likelihood that all required actions are successfully carried out.”

Read the report: Fuel imbalance and engine shutdown involving Boeing 737, VH-VZT 135 NM south of Kalgoorlie-Boulder Aerodrome, Western Australia, on 25 October 2021

Publication Date 28/02/2024

Note that in the report there was no safety issues identified and in the 'safety action' section it simply has:

Safety action by Qantas Airways
After the occurrence, Qantas communicated the factors involved to 737 flight crews.

Presumably the internal investigation and subsequent initiated safety action of Qantas were completed within a relatively short time frame? However this short investigation took 857 days, or more than 4x the target performance (KPI) time to complete?? - UDB!

MTF...P2

PS: Wonder why the following contextual information was not mentioned in the Godlike blurb or in the 'contributory factors' section of the report:

Personnel information

Captain

The captain held an Air Transport Pilot (Aeroplane) Licence (ATPL) and was appropriately qualified and authorised to conduct the flight. The captain had almost 12,000 hours total flying experience with over 5,000 hours on 737 variants. The captain was a check and training pilot for the operator and had flown about 110 hours in the previous 90 days.

As a result of the Qantas response measures to COVID-19[12], the captain was stood down from mid-April 2020 until 23 September 2020. Upon completion of simulator training, they returned to flying duties at the end of September 2020. Although the captain remained stood up after that time, their monthly rostered flying hours were lower than was usual prior to the pandemic. In the 12 months prior to the event, they flew 40% of the hours they had flown in the 12 months prior to stand down. In the 3 months immediately prior to the event flight, their monthly average flying hours were roughly half their pre-pandemic average. The captain reported that while being comfortable to fly, because of the stand down and reduced flying hours, they noted a degradation in their skills.

First officer

The FO held a Commercial Pilot (Aeroplane) Licence and was appropriately qualified and authorised to conduct the flight. The FO had about 1800 hours total flying experience and about 110 hours on the 737. The FO had flown about 24 hours in the previous 90 days. The FO was undergoing line training and was qualified to act as a first officer on revenue flights alongside a check and training captain.

The FO joined Qantas as a second officer on the Boeing 787 fleet. In 2019 they commenced FO promotion and 737 type rating training, however soon after this was delayed. The FO’s training recommenced in May 2021. As a result of Qantas’ COVID-19 response measures, the FO was stood down between September and October 2021, re-commencing flying duties mid-October 2021.