[Peetwo]

From AIPA ASRR submission:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety.

Current knowledge, post the Senate Inquiry, suggests not.

"..AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.."

Recommendation 3

AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

 
Sadly the AIPA message (large & in bold), along with Recommendation 3 seem to have been totally & utterly ignored by the 'powers to be', while the ATSB continues to play lapdog to 'other' government agencies and to be 'captured' by certain 'other' industry stakeholders.

A clear example of this embuggerance of the bureau is perfectly highlighted in my post - ATSB v NTSB: A point of comparison.  However that is IMO merely the tip of the iceberg.

In the process of putting together that post, I was searching for the interim report from the Virgin investigation AO-2013-130, to which Marty Khoury referenced in his excellent blog post. From that it would seem that the ATSB are now in the habit of deleting all records of updates to an investigation and any previous links for prelim, interim etc. reports. This apparent change in protocol/methodology is only a recent development.

Example from the MK blog post there were some comments from Ben & MK. And in those comments MK transposed a couple of screenshots from the ATSB investigation page. The last post (update) was June 3, 2015 but you will see that from the ATSB AO-2013-100 - that like the links for the prelim & interim reports - those updates also no longer exist.

Marty
Author
June 3, 2015 at 8:42 am - Reply

Waiting…

As I mentioned earlier the Virgin investigation is not an isolated aberration, you only need to go down the ATSB  aviation Investigation index page & click on any number of  'Final' reports completed, including the Qantas YMML A330 incident report. It is not until about page two with the Bulli Tops R44 FR that there is a record of a prelim report (http://atsb.gov.au/publications/investig...3-055.aspx)

Which in itself is interesting because that report was coupled with the issuing of SRs to international parties - see here - & therefore the only report likely to garner any significant international interest.

What does this mean? Well maybe not much because under the TSI Act it would seem that the ATSB is not obliged to publish interim/prelim reports etc. However, as we know, it is a very different matter when it comes to the ICAO SARPs.

It is also worth noting that - as far as I am aware - interim & prelim (in the ATSB system) reports are not normally subject to review from the Commissioners, it is only after the DIP process that the Commissioners review the DRAFT FR. This means that the Virgin Interim report where MK referenced & then stated...

Stabilised Approaches

From the ATSB report:

   Quote: Wrote:The aircraft was levelled off at about 700 ft above mean sea level (AMSL), or about 500 ft above ground level, and turned to the right to align with the runway.

The incorrect FMC programming is a mistake not that dissimilar to low risk errors made virtually every day at every airport around the globe. In almost all circumstances, a correction is quickly applied without any consideration or thought and a normal approach and landing is continued. What concerned me about the incident in Melbourne – which wasn’t asked of the ATSB in their interim summary nor discussed by mainstream media – is why a missed approach wasn’t conducted.    

Wrote:. Continuing an unstabilised approach is a causal factor in over 40% of all approach and landing accidents.
   . Approximately 70 % of rushed and unstable approaches involve an incorrect management of the descent-and-approach profile and/or energy level (i.e., being slow and/or low, being fast and/or high).
   . 56% of commercial jet airplane accidents occur during the approach and landing phases of flight and account for 44 percent of all fatalities worldwide. The approach and landing typically accounts for 16% of the total flight time.

The stable approach criteria for Virgin Australia’s long haul operation is 1000 feet… but here they were, nearly 600 feet low on an approach (below 1000 feet), and an unstable call wasn’t called for by any crew member.

The failure to execute a missed approach should likely be a significant focus of the ATSB investigation.

...has effectively been filtered out at a commissioner level. And that IMO is absolutely criminal and tantamount to a breach of S24 of the TSI Act.

MTF? Definitely...P2  

Ps For those interested here are my running notes & some very interesting links off the convoluted ATSB website  - http://auntypru.com/wp-content/uploads/2...NOTES.docx