[Peetwo]

Sunday Ramble - Beyond the pale  

For the probity of the ATSB one of the most shameful decisions (or non-decisions) of DPM Truss was to appoint Martin Dolan for a further 2 years as Chief Commissioner. Then to stand by his man after the TSBC review is quite simply beyond the pale..

From NX Media Release 3rd December 2014: Aviation safety failure

..Senator Xenophon called for the removal of head of the Australian Transport Safety Bureau (ATSB), Martin Dolan, and the establishment of an Inspector-General of Aviation to provide much-needed oversight of the ATSB and the Civil Aviation Safety Authority (CASA)...

...“The Canadian report and the Minister’s statements are further testament to the ATSB’s incompetence. The Minister is right to call for a re-opening of the investigation, but he’s wrong to ask the ATSB to do it. It needs to be done independently,” said Nick...

Well IMO that decision to stand by this Muppet is now coming home to roost, especially when you review the latest disgusting missive by BBB in the ATSB Annual Report. See P7 post here off the SMH thread...

However the self-flagellation, self-aggrandisement of BBB gets sickeningly worse in his summary of aviation investigations:

Aviation

During the year we completed 40 aviation investigations and more than 100 short factual investigations.

The most significant of these was the crash of a Robinson R44 helicopter at Bulli Tops on 21 March 2013 (AO-2013-055). This, as well as two previous similar accidents involving R44 helicopters, highlighted the danger of rigid fuel tanks in low-impact helicopter crashes, where post-impact fires may make otherwise survivable accidents deadly. We confirmed this trend with detailed statistical analysis of similar accidents in Australia and the US over a 10-year period.

While the Civil Aviation Safety Authority (CASA) had recommended that owners and operators implement the manufacturer’s service bulletin recommendation to replace the fuel tanks with bladder-type tanks that would improve resistance to post-impact fuel leaks, it was clear that they would be unlikely to meet the 30 April 2014 deadline.
Accordingly, the ATSB recommended that CASA mandate the requirement by the due date. As a result, all R44 helicopters in Australia are now compliant.

Following this action, other safety authorities in South Africa, New Zealand and Europe have also mandated the change have also mandated the change. The ATSB has issued safety recommendations to the US Federal Aviation Administration that they also take action to mandate fitting of bladder-type fuel tanks. The outcome of this investigation illustrates the importance of our investigations and the far-reaching influence safety investigations can have in ensuring transport safety for all travellers, not only those in Australia or our immediate region...

   
You might remember this (also off the SMH - post#23) back in early June:   

In case you needed anymore proof that the whole point of Dolan being the front man in the Bulli Tops media release, is purely a disgusting PR sham to grab the limelight away from recent bad press, here it is...FFS :

Tweet from ATSB this AM:

@atsbinfo warning on helicopter fuel tanks may lead to worldwide aviation safety changes http://www.illawarramercury.com.au/story/3126661/

  
And this was the article from the Illawarra Mercury (where the last sentence (in bold) will be conveniently overlooked by Beaker & the ATSB):

Bulli Tops helicopter crash sparks global warning

By MICHELLE WEBSTER
June 4, 2015, 9 p.m.

A horrific helicopter crash at Bulli Tops which claimed the lives of four former CSIRO scientists in March, 2013, may lead to worldwide aviation safety changes...

California-based Robinson Helicopter Company issued a service bulletin to R44 operators in December, 2010, telling them to swap to flexible fuel tanks.

Some on here will remember that at Budget Estimates in May 2013 (i.e. 2 months after the tragic Bulli tops accident), the matter of the R44 post impact fire accidents were the subject of Senate questioning. Here is a copy of a post of mine off the UP from that time:

Yep the list is growing and the stench is rising!

--------------------------------------------------------------------------------

You can add the Cousin's to that list...remember this from sub16:

“We have been to Martin Dolan Chief Commissioner ATSB, Albanese, John McCormick, Local Member John Castrilli - who did write a letter to CASA on our behalf but that was it! John McCormick insulted us in his response stating that "CASA is unaware of any other accidents involving this company’s aircraft". Oh My God how insulting to our intelligence. So in their eyes Kenny's Mob have never been involved in other incident!

How many fatalities does a Company need to have to be anything recorded as an ACCIDENT! At the inquest the CEO of Heliworks was questioned about his Statutory Declaration and had he completed - he disclosed he did not complete it and the Company had told him what to write! How could that be admissable in a court of law?

They were aware that this cowboy operation existed out at the Bungles but once again NO ONE would do a thing to stop them...............

It took 2 yrs 7 mths after the accident for the inquest to be held and we did not get the final report until a further 6 months!! Over 3 years!!”

Then

“Well we had our inquest which was an absolute joke and embarrassment for the fact that so many documents were not produced / lost / created etc and no one did a thing about it. Our Coroner Ms Fricker left a lot to be desired and the fact that in the 2 years 7 months not one person in the court room excluding us had even visited the accident site or gone out to witness just what happens out there. We came away just blown away with the fact that so many things were dismissed/ allowed/undisclosed and were allowed to be.

That smell of money I think well and truly came into play!!!
I personally lost all respect for our government representatives, law, safety authorities after sitting in that court room for 5 days and listened to excuses on their behalf...instead of reasons to rectify and was horrified after the evidence given that it was declared and accident.

As I said in court this was an Accident waiting to happen and will occur again!!The coroner in her report even noted the number of helicopter accidents just since the inquest - approx 4 month....and not one recommendation was handed down. She used the words like Breached and Failed to comply in her report and yet not one
recommendation.”

Carolyn Cousins. (mother of Jessica Cousins) Slingair Robinson 44 Bungle Bungles 14

September 2008 4 fatalities

Although according to Beaker this accident was a high-energy impact:

Mr Dolan: There had been a number of post-crash fires associated with R44 helicopters. In the vast majority of those cases they represented high-energy impacts, which is to say accidents that were unlikely to have been survivable and which would have led to a post-crash fire in almost any helicopter.

Senator XENOPHON: So you are saying that the retrofitting would not have made any difference?

Mr Dolan: That would be our general assessment.

Senator XENOPHON: Take it on notice, because I have a few other matters to raise. You are saying that, from a causation point of view, even retrofitting the helicopters with that protective bladder, it still would have been a fatal accident?

Mr Dolan: On the facts that were available to us. We are not aware of any previous to Cessnock. I do not think we are aware of any of the low-energy collisions leading to that sort of thing. There were, as you say, a number of high-energy collisions that would have led to a ruptured fuel tank in any helicopter and therefore a great likelihood of a post-crash fire. Those are the sorts of accidents that generally are not survivable.

But on the evidence in the bureau report it would appear that there was a strong possibility the pilot at least survived the crash impact only to be overcome by the post impact fire, from the report:

Medical and pathological information
The post-mortem examinations for all occupants of the helicopter described varying degrees of injuries consistent with the high vertical velocity impact. All sustained extensive thermal injury.

The pilot’s post-mortem report indicated that he was found ‘...a slight distance from the damaged aircraft.’

You will notice that the post-mortem didn't appear to explore how the victims died i.e. did they succumb to their impact injuries or the 'extensive thermal injuries'. Nor was IMO the post-survivability issues properly explored by the ATSB. It was almost as if the ATSB accept that if a chopper comes (in particular a Robbo) down hard it will inevitably burn!

Yes 004 it will be interesting to watch and I bet there will be a couple of interested Senators tuned in as well..given the QONs outstanding on the subject of post-impact fires and R44s

Here's the links for the high energy post-impact fire fatalities to which Senator X refers:
http://www.atsb.gov.au/media/1533519/ao2008062.pdf

http://www.atsb.gov.au/media/1361537/aai...79_001.pdf

http://www.atsb.gov.au/media/24556/aair2...46_001.pdf

And here is a link for the report from the Jaspers Brush tragedy - AO-2012-021 - that included these two safety issues:

Fitment of rubber, bladder-type fuel tanks to R44 helicopters

And in ICAO Annex 13 Ch 6 under Safety  Recommendations  it is stated...

"..6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO..."

So what is the ATSB excuse for sitting on these SRs until now (over two years after the fact)?? No this is just another cynical attempt to gain credibility where none is due..
FFS get rid of the Muppet.    

I guess it is not surprising then that BBB is hanging his hat on the Bulli Tops R44 crash investigation but I very much contend the veracity of most of the rest of his statement regarding the safety risk mitigation SR and its impact/recognition by other State NAAs/AAIs, in particular the FAA.

The following is an article from off Bloomberg Business, which perfectly highlights what I mean:

The FAA Wants New Helicopters to Have Crash-Resistant Fuel Tanks

Alan Levin AlanLevin1
October 21, 2015 — 8:00 PM AEDT Updated on October 22, 2015 — 6:25 AM AEDT

• Reinforced fuel tanks would decrease fires after accidents
  
• Regulators ask industry panel to study broad safety changes
  

U.S. aviation regulators plan to require all newly built helicopters to have crash-resistant fuel tanks to cut the risks of leaks and deadly fires after accidents as part of the broadest effort in decades to improve rotor-aircraft safety.

The Federal Aviation Administration asked an advisory committee to draft new regulations requiring the technology, according to a Sept. 28 letter sent to the National Transportation Safety Board and posted on the agency’s website.

That marks a significant shift on a controversial safety issue that has been linked to more than 200 civilian deaths since 1994. The U.S. Army has cut casualties from fires after helicopter crashes with the use of bladder-like fuel tank linings developed during the Vietnam War, but some operators and manufacturers argued that such technology was too expensive and would hamper operations.

“It is going to be extremely difficult and expensive to figure out how to incorporate it into an existing design,” Walter Desrosier, the vice president for engineering and maintenance at the General Aviation Manufacturers Association trade group, said in an interview.

The FAA asked the industry panel, called the Aviation Rulemaking Advisory Committee, to explore ways to better protect helicopter occupants from crashes, according to an Oct. 8 letter. It was spurred by a recent study showing better protections would save lives, according to the FAA letter. The agency also is asking for a review of other safety measures, including requiring seats that don’t break loose in accidents and structural changes to prevent occupants from being crushed.

New Standards
The action was spurred by emerging data on helicopter crashes and how to prevent them in the future, FAA Administrator Michael Huerta said in an interview Wednesday. “What we want to do is take advantage of what more do we know,” Huerta said.

In the 1980s and 1990s, the FAA adopted helicopter safety standards for new designs. Since then, however, only 16 percent or fewer helicopters sold have the protections because manufacturers mainly produce aircraft based on older designs.

“This approach has resulted in a very low incorporation rate of occupant protection features into the rotorcraft fleet, and fatal accidents remain unacceptably high,” the FAA said.

While the helicopter industry supports reviewing whether new standards make sense, it hasn’t endorsed any specific measures, Desrosier said. Requiring fuel-tank upgrades may cost manufacturers millions of dollars, an expense that wouldn’t justify whatever benefit it creates, he said.

One option may be to create a streamlined protection system that would be cheaper to install on existing models, he said.

UT, Airbus
GAMA represents helicopter makers including United Technologies Corp.’s Sikorsky Aircraft division, Airbus Group SE’s Airbus Helicopters Inc. and Textron Inc.’s Bell Helicopter. GAMA members delivered 971 new helicopters last year, according to the group’s annual statistical report.

The Helicopter Association International, a trade group representing fleet operators, supports the FAA’s effort though it hasn’t endorsed changes to fuel tanks or other specific measures, said Chris Dancy, a spokesman. The group will work on the advisory committee, he said.

Safer fuel tanks were developed by the military in the 1960s in response to the high number of casualties in Vietnam after helicopters caught fire in the aftermath of crashes that were otherwise survivable.

Companies including Robertson Fuel Systems LLC of Tempe, Arizona, have built such tanks for military aircraft and ground vehicles, as well as race cars, according to company founder S. Harry Robertson. Their system, known as “Robbie Tanks,” work by preventing leaks even after being pierced by bullets or fractured by an impact.

The safety board on July 23 urged the FAA to impose stricter standards. The FAA agrees with the NTSB on the need to upgrade fuel tanks and has started the rulemaking process, the FAA’s Huerta wrote in the September letter.

Wichita Crash

The NTSB’s July recommendation was prompted by an Oct. 4, 2014, helicopter accident in Wichita Falls, Texas. Surveillance video that captured the crash showed a flight nurse and paramedic survived the impact, but died when fuel spilled and ignited, according to the NTSB.

From 1994 to 2013, there were 135 helicopter accidents in which fire broke out after impact, resulting in 221 deaths and 37 serious injuries, according to NTSB. Of those crashes, only three had crash-resistant fuel systems.

After the U.S. Army began requiring fuel protections in the 1960s, it saw a 75 percent decrease in injuries and zero fatalities attributed to post-crash fires, according to the NTSB letter. The letter didn’t specify the years when the decrease took place or how many deaths there were prior to the requirement taking effect.

The FAA didn’t set a deadline for when it would complete its new regulations. It must first draft the rule and then allow the public and industry to comment.

 Hmm...didn't see any mention of the ATSB's belatedly issued SR or the Bulli Tops FR...

Perhaps it gets a mention in the NTSB Wichita FR - NTSB Identification: CEN15FA003 ...err nope  

A how to - courtesy the NTSB.

Oh well at least we do get a perfect example of the power of a well worded safety recommendation - Safety Recommendation A-15-012 

TO THE FEDERAL AVIATION ADMINISTRATION: Require, for all newly manufactured rotorcraft regardless of the design’s original certification date, that the fuel systems meet the crashworthiness requirements of 14 Code of Federal Regulations 27.952 or 29.952, “Fuel System Crash Resistance.”

Reply:

-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) agrees with this recommendation and has started the rulemaking process by sending a tasking statement to the Aviation Rulemaking Advisory Committee. Any resulting part 27 or part 29 rulemaking the FAA proposes would require that we give public notice of our intent to implement a rule change and consider any comments to our proposal. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by September 30, 2016.

MTF..P2