[Peetwo]

Embuggerance & investigative probity - In the Sleepy Hollow shelf-wared tales of embuggerance, there is one case, that of Airtex, that keeps on rearing its ugly, festering head.  Like the long trail of industry exemptions, the Airtex ET provides many puerile examples of CASA double standards in regulatory enforcement. How this - vindictive, hypocritical trail of nonsensical, big "R" embuggerance - all began is hard to define but it escalated not long after the fatal accident into Botany Bay of Metro VH-OZA and culminated with the tragic accident on 15 June 2010 of Skymaster (sister company) VH-PGW Mojave at Canley Vale.

Either way the Airtex case now sits as a benchmark of the extreme lengths of enforcement persecution that CASA deployed throughout the McCormick years.   
 
Another Airtex 'point of comparison'.

At PAIN we have quite often compared the treatment/oversight by CASA of PelAir versus Airtex, with there being 'passing strange' aberrations/differences in enforcement policy from the very same overseeing CASA Office. Even more bizarrely this interpretation dichotomy was also reflected within the supposedly independent ATSB investigations of accidents involving both (one former) AOC holders & associated owner companies & management. This dichotomy may also be a reflection of the fact that the Airtex/Skymaster accidents involved fatalities & with the PelAir ditching pax & crew survived.   

Okay now, as luck would have it, we have a completed ATSB investigation of an occurrence very similar to VH-OZA, which fortunately this time did not end in a tragic accident or survived ditching. It also occurred in the jurisdiction of another CASA region.      

Two weeks ago the ATSB released a Final Report for investigation AO-2014-147, here is the summary for what happened in that incident:

On 3 September 2014, at about 0215 Eastern Standard Time (EST),[1] a Fairchild SA227 aircraft, registered VH-UUO, took off from Brisbane Airport, Queensland for a freight charter flight to Bankstown Airport, New South Wales, with one pilot on board. Following the take-off, when at about 200 ft above ground level, the pilot observed the horizontal situation indicator (HSI) indicating a right turn although the aircraft was still maintaining runway direction. The pilot reported that the attitude indicator (AI) displayed alternately a nose up and nose down attitude.

When at about 1,600 ft above ground level, the pilot advised air traffic control of a ‘minor problem with heading’ and was directed to conduct a right turn onto an easterly heading to avoid noise sensitive areas. The pilot turned the aircraft to the right, towards the Pacific Ocean, while referring to the HSI on the co-pilot’s instrument panel, which was providing more accurate heading information. The pilot was aware that the captain’s AI and HSI instruments were providing erroneous indications, but became disoriented by continuing to scan those instruments. The pilot looked out of the window in an attempt to gain a visual reference but could see only blackness.

The pilot continued a shallow right turn until the lights of runway 19 became visible. The aircraft landed back at Brisbane, on runway 19 about 150 kg above the aircraft’s maximum landing weight.

 
This incident had some very real similarities to the tragic accident of VH-OZA  (reference: ATSB - AO-2008-026): 

On 9 April 2008, at 2325 Eastern Standard Time, a Fairchild Industries Inc. SA227-AC (Metro III) aircraft, registered VH-OZA, departed Sydney Airport, New South Wales on a freight charter flight to Brisbane, Queensland with one pilot on board. The aircraft was subsequently observed on radar to be turning right, contrary to air traffic control instructions to turn left to an easterly heading. The pilot reported that he had a 'slight technical fault' and no other transmissions were heard from the pilot.

Recorded radar data showed the aircraft turning right and then left, followed by a descent and climb, a second right turn and a second descent before radar returns were lost when the aircraft was at an altitude of 3,740 ft above mean sea level and descending at over 10,000 ft/min. Air traffic control initiated search actions and search vessels later recovered a small amount of aircraft wreckage floating in the ocean, south of the last recorded radar position. The pilot was presumed to be fatally injured and the aircraft was destroyed.

Both of the aircraft's on-board flight recorders were subsequently recovered from the ocean floor. They contained data from a number of previous flights, but not for the accident flight. There was no evidence of a midair breakup of the aircraft...

There were even similarities in the 'contributory factors' sections:

VH-UUO:
 
Contributing factors

• The pilot did not correctly configure some of the cockpit instruments and systems prior to taxiing, or detect or correct the problem with the primary heading reference prior to take-off. This led to erroneous heading information being presented to the pilot.

• The primary attitude indicator probably malfunctioned intermittently after take-off, leading to the pilot being presented with erroneous attitude information.

VH-OZA:

Contributing safety factors

• It was very likely that the aircraft’s alternating current electrical power system

was not energised at any time during the flight.

• It was very likely that the aircraft became airborne without a functioning

primary attitude reference or autopilot that, combined with the added workload

of managing the ‘slight technical fault’, led to pilot spatial disorientation and

subsequent loss of control.

However that is where the reports rapidly start to diverge:

VH-UUO:

Other factors that increased risk

• The attitude indicator had been in service for 1,783 hours, which exceeded its recommended time in service of 1,200 hours.

• The pilot did not declare an emergency or communicate the magnitude of the problem to ATC, but only advised of a minor heading issue. ATC issued a right turn due to noise abatement (and away from the city lights), and two frequency changes in accordance with normal ATC service provision. Had the pilot communicated the issue to ATC, they could have provided assistance.

Other findings

• The flight data recorder did not have any valid recorded data for vertical acceleration.

VH-OZA:

Other safety factors

• The pilot’s Metro III endorsement training was not conducted in accordance with the operator’s approved training and checking manual , with the result that the pilot’s competence and ultimately, safety of the operation could not be assured. [Significant safety issue]

• The chief pilot was performing the duties and responsibilities of several key positions in the operator’s organisational structure, increasing the risk of omissions in the operator’s training and checking requirements.

• The conduct of the flight single-pilot increased the risk of errors of omission, such as not turning on or noticing the failure of aircraft items and systems, or complying with directions.

Okay extracts from the individual safety issues & actions sections.
First from VH-UUO FR:

Safety issues and actions

Additional safety action



Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following safety actions in response to this occurrence.



Operator of VH-UUO



The operator of VH-UUO created a simulator exercise based on the incident. The training managers are working towards a cyclic pattern for the company flight crew base checks to ensure systematic coverage of test scenarios.


Following the incident, the operator’s Quick Reference Handbook (QRH) reference for inverter failure was amended to become a ‘memory item’. Thus if an inverter fails, particularly at a critical phase of flight, the pilot can take the necessary steps to swap inverters without referencing the QRH.

The operator has subsequently removed the AIM 500 AI from the captain’s instrument panel and fitted an AIM 510, which carried the appropriate authorisation. The operator replaced the vertical accelerometer to provide valid FDR data. The engineering order (EO) was amended to label the accelerometer as a single vertical axis accelerometer. The test procedure for the accelerometer was amended to check for vertical acceleration data only.

 
That's it, finished, no further mention of the AI being 583 hrs overdue for replacement, no mention or apparent interest from CASA in this incident. All of which is fine because the operator has apparently heeded the safety message and has put in place effective risk mitigation measures.
Next VH-OZA:

SAFETY ACTION


The safety issues identified during this investigation are listed in the Findings and


Safety Actions sections of this report. The Australian Transport Safety Bureau


(ATSB) expects that all safety issues identified by the investigation should be
addressed by the relevant organisation(s). In addressing those issues, the ATSBprefers to encourage relevant organisation(s) to proactively initiate safety action,rather than to issue formal safety recommendations or safety advisory notices.


All of the responsible organisations for the safety issues identified during this
investigation were given a draft report and invited to provide submissions. As partof that process, each organisation was asked to communicate what safety actions, ifany, they had carried out or were planning to carry out in relation to each safetyissue relevant to their organisation.



Conduct of training not in accordance with operator
and regulatory requirements.

Significant safety issue

The pilot’s Metro III endorsement training was not conducted in accordance with
the operator’s operations manual and Civil Aviation Safety Authority regulationsgoverning training and checking requirements, with the result that the pilot’scompetence and ultimately, safety of the operation cannot be assured.

Action by the Civil Aviation Safety Authority


On 10 July 2008, Civil Aviation Safety Authority (CASA) officers met with the aircraft operator to discuss the results of the June 2008 risk-based audit. As a result of those meetings, on 11 July 2008 CASA imposed the following conditions on the air operator’s certificate:


• no passenger carrying charter or aerial work operations were to be conducted whilst the then chief pilot held that position, with such operations only to resume upon CASA approval of a new chief pilot.


• the operator was required to develop multi-crew procedures in order to crew Metro aircraft with two qualified pilots when carrying passengers, with those procedures to be in place prior to such operations.


• by 18 July 2008, the operator was required to implement a system that printed pilot flight and duty time records to ensure a permanent record is kept.


• by 25 July 2008, the operator was to implement a confidential reporting system to provide the chief executive officer (CEO) with information relating to poor operational standards or hazards and risks within their operations.


• by 31 July 2008, the operator duplicate, via a secure back-up process, all computerised operator records and keeps these back-ups in a secure place


• by 31 August 2008, the operator was to employ an appropriately-qualified independent auditor that was acceptable to CASA. The auditor was required to conduct comprehensive quality and aviation safety systems audits on a 6-monthly schedule, and provide CASA with a copy of each audit report within 3 weeks of the completion of the audit


• by 30 September 2008, the operator was required to develop a comprehensive, company-wide safety management system that was fully supported by the CEO

• by 30 September 2008, the operator was to review and where required, amended the operations manual, any amendments were to be submitted to CASA for acceptance.


Action by the aircraft operator


In response to the issues that were identified in CASA’s risk-based audit of June 2008, on 30 July 2008 the operator advised CASA of the following actions to rectify those issues:


• the operations manual was being rewritten to:


– bring the operator’s training and checking into line with the regulations and address multi-crew operations


– ensure that base and line checks accurately reflected the operator’s procedures and testing requirements by reference to specific test-content forms


– include the requirement for all inducted pilots to complete ‘wet drill’ training on the use of life jackets and life rafts. The results of that training would be recorded and renewed annually


– ensure the review of ground course theory examinations and that they were corrected to 100% knowledge of the subject


– ensure the completion of formal ground courses and that the training and syllabuses were documented


– ensure that pilots undertook pressurisation endorsement with a minimum training criteria


• several pilots were being retrained as required to meet the operator’s endorsement training requirements


• the operator’s computer-based flight and duty time records were password protected and a monthly copy of each crew member’s record would be printed out and placed on the individual’s file


• flight crews had been informed about the importance of accurately completing paperwork


• the head of training and checking had resigned and a new individual had been approved by CASA


• one pilot who had been identified as not having sufficient in command under supervision hours had been recertified.


Subsequently, on 17 September 2008, the operator provided an amended operations manual to CASA for review. That included amendments to Part C of the manual.


On 16 December 2008, CASA issued a new Air Operators Certificate to the operator.


ATSB assessment of CASA and operator action


The ATSB is satisfied that in combination, the action taken by CASA, and response to the CASA action by the aircraft operator, adequately addresses the safety issue.

Additional safety action

Aircraft operator

Although no safety issue was identified as a result of this investigation, on 6 August 2008, the operator notified CASA that, as part of its new safety management system, a safety committee had been implemented that comprised the CEO, general manager, chief pilot, head of training and checking, safety manager and a pilot or engineering representative.

Now again I am not being critical of the outcome, on the contrary it is a perfect example of how the system is supposed to work, the ATSB identifies significant safety issues with the AOC holders operations, which implicate CASA through some lack of oversight issues.

CASA (much like with PelAir) puts in place requirements they feel need to be addressed before granting the company an AOC renewal.

The company embraces & proactively addresses these requirements and even further to the CASA expectations puts in place a SMS to help identify & mitigate any future safety issues.

The trouble for Airtex was that Wodger (backed by McComic) then came on the scene and finally they were done by association with Skymaster & the Canley Vale tragedy. 

So ends my POC...


MTF...P2