[Peetwo]

World's best practice in CYA Aviation Accident Investigation -

K - If, you thought the Pel-Air epistle was an aberration; a one off, think again.  This latest abomination, following closely on the heels of the Mildura aberration speaks clearly of the total shambles ATSB has become under Dolan.

IMO there is no better example of how much damage Dolan has inflicted on the ATSB, in the 7 years he has been in charge, than in this 'interim report'.

To begin why after 847 days are we just now getting an interim report? Surely as a 'accident' investigation proper resources should have been allocated to progress this investigation beyond an interim report. Apparently this report was initiated because a 'safety issue' had only just been identified?

Although the investigation is not yet complete and covers a range of areas, a safety issue has been identified that, in the interests of safety, needs to be brought to the attention of the industry before the investigation is completed.

  
Yet if you refer to the 1st interim report issued 2 years ago (10 June 2014) even Blind Freddy can see that the 'safety issue' now identified...

Inadvertent activation of the elevator control system - pitch uncoupling mechanism

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
ATSB Safety Issue No: AO-2014-032-SI-01

 ...was also clearly identified back then:

...The flight crew of the earlier pitch‑disconnect flight and the engineers involved in the post-flight maintenance were interviewed and the damage to the aircraft was inspected at Albury. The ATSB downloaded data for the pitch-disconnect flight and subsequent flights from the flight data recorder and data for the pitch‑disconnect flight and last flight from the cockpit voice recorders that were installed in the aircraft for those flights.

Initial examination

An initial examination of the recorded data showed that when the airspeed approached 240 kt, at about 8,500 ft during the descent into Sydney on 20 February, the first officer used touch control steering and manually pitched the aircraft up. The airspeed increased again and then both the first officer and captain pulled on the control column. Shortly after, when the vertical load factor was increasing through 1.8 g, the first officer began to push the control column. The differential force on the control column that resulted from the captain and first officer applying an opposing force exceeded the differential force required to generate a pitch disconnect. Each pilot was then controlling the elevator on their side of the aircraft in opposite directions for a brief period before the first officer released his control column.

The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser...

 
IMO this is another blatant attempt to obfuscate a very serious causal chain of events that, if not for the luck of the gods, could have led to the worst recorded number of fatalities for any Australian aviation accident. We must remember that VH-FVR flew 13 more sectors with a severely bent horizontal stabiliser, before it was grounded in Albury after a suspected bird strike occurrence.

The other point to note is that the only reason this occurrence is listed as an 'accident' is due to the cabin crew member being seriously injured in the course of the event:

At some point the cabin crew called the cockpit and advised that the senior cabin crew member had injured her leg and that it might be broken. In the next contact with air traffic control the crew asked for an ambulance to be available after landing. The crew also made a PAN[4] call and requested runway 16 Right to minimise taxi time on the ground. Air traffic control agreed to that request.

   
{P2 comment: One wonders that if the unfortunate injury to the cabin crew member did not occur whether there would have even been a ASIR submitted to the ATSB}

Another indicator, that backs both the P7 & P9 summations, that this is another attempted ATSB whitewashed investigation is buried in the following text from the interim report:

..However, it shows that the aircraft was in a situation where inadvertent control inputs could lead to catastrophic failure of the horizontal stabiliser.

In normal operation, flight crew should not be making uncoordinated simultaneous control inputs. However this, and a number of other in-flight pitch disconnect occurrences, indicate that the pre‑existing procedural risk controls alone may not be sufficient to prevent this type of occurrence. Also, on this occasion, significant structural damage was done to the aircraft before the crew were alerted to, and able to react to the disconnection of the left and right pitch systems. Consequently, the ATSB is investigating whether the design of the pitch control and associated warning systems increases the likelihood of potentially catastrophic damage occurring when flight crew inadvertently make opposing pitch control inputs. The final report will contain a detailed assessment of this aspect of the investigation...

 
 And also from earlier in the report:

Although not shown in the previous figures, the yaw axis effort (pilot load applied to the rudder pedals), indicated that the applied load exceeded the value that would result in the automatic disconnection of the autopilot.[14] That load exceedance occurred at 05:40:51.9, about the time that the autopilot disconnected. However, due to the data resolution and lack of a parameter that monitored the pilot’s disconnect button, it could not be determined if the autopilot disconnection was due to the load exceedance or the manual disconnection reported by the captain.

 Now I know that this incident, if nothing else, proves ATR is obviously an extremely robust aircraft but the statements made in the above interim report text should IMO have automatically created a worldwide safety alert to this potential safety issue. Not a grounding as such but a heads up leading to a mandatory AD or safety notice. For history has proven over and over that if it can be done once the chances are it can be done again.
That important message should not be buried in the general context of an ATSB report (interim or otherwise) and left basically as a general comment for further investigation. What are we to wait another 847 days for the ATSB to tell us they've identified yet another safety issue -

Please someone(?), anyone(?) bring back sanity & veracity to the ATSB...  

MTF...P2

Ps  Q/ Why was there no 2nd interim report (update on investigation) on the 1st anniversary of the investigation?