[Peetwo]

ATSB O&O'd investigation No.??

Peetwo

[quote pid='393' dateline='1428906978']

[/url]Who is kidding who??

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training wheels good catch and interesting article (& photo) from the [url=http://www.bordermail.com.au/story/2136758/bird-puts-plane-out-of-service/]Border Mail...

VH-FTS - How are CASA and the ATSB hiding things? I didn't realise they were the ones obligated to tell the press every time there was an accident or incident? Once the report is finalised, yes, but not during the initial investigation. I'd say they are probably doing their job properly behind the scenes - just because you, the pruner, doesn't know about it doesn't mean it's being handled poorly.

FTS I'm sure that you're probably right in regards to the investigators on the coalface doing their job properly, however I beg to differ with the rest of your statement.

Both of the occurrences in this case were listed as 'accidents' and both are being investigated. History shows that anytime a serious incident/accident is notified to the ATSB they will invariably post a media release within a day, if not hours, of the occurrence.

It is interesting that the BM article was released on the 08/03/14, some 11 days after the 2nd incident/accident, yet the article states:

The incidents are being treated as separate.

A Virgin Australia spokesman, Nathan Scholz, said there was no evidence linking the two matters.

Mr Scholz said that on February 20, the Sydney-bound flight struck turbulence that led to a crew member being injured and Virgin notified the bureau.

He said five days later the pilot reported a bird strike mid-flight and found damage to the outside of the aircraft upon landing to Albury.

However if we refer to the ATSB weekly summary lists for the 28 Feb 14 (entry 168) & 7 Mar 14(entry 182) we get the following notifications for the apparently unrelated occurrences (formatted differently but you'll get the picture):

20/02/2014 *201400786*Accident Yes - AO-2014-032* near Sydney Aerodrome* NSW* ATR - GIE Avions de Transport Regional ATR72-212A*
Air Transport High Capacity*Passenger* C * CTA

During cruise, the aircraft encountered severe turbulence resulting in a cabin crew member receiving a serious injury. The investigation is continuing.

25/02/2014*201400985*Accident Yes - AO-2014-032* near Albury Aerodrome* NSW * ATR - GIE Avions de Transport Regional ATR72-212A*
Air Transport High Capacity*Passenger* D * CTR

During a post flight inspection, substantial damage to the aircraft's tail assembly was detected. The investigation is continuing.

From this information we can establish that; (a) both events were listed as accidents and; (b) for some strange reason (& unbeknown to the BM reporter & VA spokesman) the bureau has given these (unrelated) events the same investigation number.

{Comment: It is also passing strange that the bureau makes no mention of the PIC's notified bird strike incident}

OK clear as mud so far?? Then we move further down the article to this bit right at the end...

"...The bureau spokesman in Canberra said a preliminary report would be prepared within 30 days..."

The 30 days passed on the 27th of March apparently without a prelim report being issued... However if you refer to investigation number AO-2014-032 you will see that it was last updated on the 25 March 2014. So technically speaking the bureau has come within it's promised deadline of 30 days. What is unclear is how the two occurrences were notified to the required parties (as per Annex 13 para 7.1) and whether there was a Preliminary report issued (to those parties) prior to the 30 days (as per para 7.4 of Annex 13).

Oh well I'm sure it is all above board.. However if that is the case when is the bureau going to make the Prelim report available to the rest of the world??

 
It should be noted that it is now 2 years 1 month & 27 days since the original incident (classified as an accident). And it is 1 year 10 months and 6 days since the investigation page has been updated - UFB! 

[/quote]

In an update to the ATSB O&O accident investigation - AO-2014-032 - here is some more commentary off the PT blog, note how the thread drifts to the point where Ben's original  message is totally lost:

20
Ventus45
Posted April 15, 2016 at 12:16 pm | Permalink
ggm said:-

“It feels like a recipe to actually MAKE bad things ensue, because you train the company to get away with not complying.”

Spot on mate.

Then Fred said:-

“at the risk of drawing the ire of some commentators..”

You have ………

“I should point out that according to Annex 13, interim reports are recommended in cases where the final report cannot be released within twelve months. They are not required.”
OK Fred, I will take you up on that.

THE PROBLEM is embedded in just that kind of “lawyer’s attitude”.

You do remember the little “game” our Chief Commissioner of the ATSB, Mr Martin Dolan, played on Senator David Fawcett in Senate Estimates during the PelAir – Norfolk Island Ditching hearings ?

It was all about which “edition” of Annex 13 applied, the “wording” – “shall” or “should”.
Fred, Annex 13 has been edited and amended so many times over the years, that it has been become a joke.

There is a thread on Aunty Pru about “investigative probity” (i.e. the “LACK OF IT”).
See here:-

http://auntypru.com/forum/-The-search-for-investigative-probity?pid=393#pid393

The sad fact is, that the “joke” will eventually be on people like you, those who fall for the “spin” and BS.

That ATR could have lost it’s tail in the next encounter with “moderate turbulence”.
It was only “grounded” after 5 days and 13 flights.

How lucky were the passengers and crews of those 13 flights ?

Do any of those people know they were in such potential peril ?

Should they ?

21
Fred
Posted April 15, 2016 at 12:55 pm | Permalink

Oh FFS get off your pedestal. I merely pointed out what Annex 13 says about interim reports. I also stated “I’m not excusing the ATSB for its lack of transparency…”.

22
Ventus45
Posted April 15, 2016 at 1:19 pm | Permalink
Fred, “not excusing” is not enough, it doesn’t cut the mustard.

Fred, a lot more people NEED to get up on the pedestal, and YELL – LOUD AND LONG – until parliament hears – AND ACTS.

If they don’t, what they will eventually hear, is a bloody lound “bank” and / or “boom” when an airliner crashes.

Then they will hear something else, that they will not be able to IGNORE.

23
Dan Dair
Posted April 15, 2016 at 4:29 pm | Permalink
Ventus45,

“a lot more people NEED to get up on the pedestal, and YELL – LOUD AND LONG – until parliament hears – AND ACTS”

If you truly believe that,
why are you wasting your time telling us, on this blog;
ie. the already converted,

instead of directly ‘yelling – loud and long’ at the politicians & regulators.?

After that Dan Dair drifts the thread for three more posts till Fred again posts:

Dan (#25),

Yes, I would certainly expect the ATSB to consider that aspect during its investigation. However, the ATSB can only make safety recommendations; it can’t enforce their implementation. That job belongs to the regulators.

&..then out of the blue WJR Hamilton posts   :

Folks,
At the risk of sounding like a lawyer (which I am not), under Australia’s complex, confusing and often contradictory air law, one thing remains clear. It is the person/entity who is the “registered operator” who, at all material times, remains responsible for the airworthiness of an aircraft.

Hiring of a maintenance contractor (the norm rather than the exception, these days) in no way lessens the responsibility of the “registered operator”. It doesn’t become a joint responsibility,(although a maintenance organisation may commit its own non-compliance with the law) it remains the responsibility of the registered operator.

As to the real reason for the initial incident, or the subsequent events, I have little confidence is seeing a satisfactory report.

However I would like to focus on these two quotes courtesy of Fred, first the one that captured the Ventus45 ire :

"..“The ATSB failed to produce a first or second anniversary interim report into these matters in accordance with ICAO protocols”.

I’m not excusing the ATSB for its lack of transparency in this matter. Nevertheless, at the risk of drawing the ire of some commentators, I should point out that according to Annex 13, interim reports are recommended in cases where the final report cannot be released within twelve months. They are not required..."

"..6.6 Recommendation.— [i]The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing theprogress of the investigation and any safety issues raised.."
[/i]
Okay I can (sort of) accept that, however as Ventus pointed out that after the very damning findings of the Senate AAI (PelAir) inquiry (where it was found the ATSB is a repeat offender of taking the Mickey Bliss of ICAO and Annex 13) I would of thought it prudent to at least appear to be compliant with the Annex.

It is also worth noting that for all traceable ATSB defined 'serious incident' investigations (active & historical) involving HCRPT aircraft, there has always been a interim report or statement issued on each anniversary of the occurrence. Given this occurrence was actually classified as an 'accident' then I would of thought it more prudent to be consistent with the accepted ICAO AAI Annex 13 principles.

Another point to note is that under A13 that a Preliminary report is required for.. 

"Accidents to aircraft over 2 250 kg

7.1 When the aircraft involved in an accident is of a maximum mass of over 2 250 kg, the State conducting the investigation shall send the Preliminary Report to..
...&
"..7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available..."


There does not appear to have been a prelim report issued either within 30 days or since for that matter. Oh but that's right for Annex 13 7.2 we have a notified difference:

"..Detail of Differences: Australia will comply with the standard for the more complex accidents. However, for some less complex investigations Australia does not prepare a Preliminary Report.."


Hmm...given the level of comments so far (above) I would of thought this was anything but a 'less complex' investigation?? 

While on the subject of the ATSB normalised deficiency of complying with ICAO Annex 13, if we refer to the more than 3000 Oz notified differences to ICAO under Annex 13 - https://www.airservicesaustralia.com/aip...5-h104.pdf - perhaps I can straigten out Fred's misconception that the ATSB routinely issue safety recommendations when a significant safety issue is identified in the course of an investigation:  

Fred - "the ATSB can only make safety recommendations; it can’t enforce their implementation. That job belongs to the regulators..."

From page 2 of the 10 pages (all 39 of them) of ATSB NDs of A13, safety recommendation defintion:

"..Essence of definition adopted in legislation and in policy and procedures documents. However, Australia reserves the term safety recommendation for making formal recommendations which are used as a last resort..."

This ND has in recent years (since 2008) has been stringently adhered to by the ATSB under Mr Dolan, to the point that the once obligatory SR for SSIs is almost redundant. The following is a link for a PAIN report that highlights the demise of the SR: http://auntypru.com/wp-content/uploads/2...opin_2.pdf

This was originally compiled for & during the PelAir inquiry so it is now somewhat post dated but the signs are that the SR decline trend has since stabilised.   

MTF..P2