[Peetwo]

"There's a hole in the cheese dear Liza, dear Liza??"

Who'd of thought? The Ferryman doing 'an evening twiddle' just short of the 'witching hour' on a Sunday night? Maybe like the rest of us mere mortals, this bollocks daylight savings has disturbed his evening routine..

Anyway job well done Mr "K"...   (Ps & TY for the edit I was bit rushed with my last - )

Ok onwards & downwards with the dot joining...

Quote from: Opinion :-ATSB since 2003.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they provide further examples of compromised ATSB Final Reports.

In case you need a reminder of the circumstances of the Darwin Brasilia accident, here is a disturbing ATSB simulator animation of that tragic C&T accident: 

From earlier post#33 "K" said:

..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...

And just before the Senate PelAir inquiry, on the 6th August 2012, a certain 'senior' ATSB Transport Safety Investigator (who I believe was actually Dr (BASR) Walker), said this about the Braz tragedy:


{P2 comment - To put this in context this was just prior to the release of the original nearly 3 year, totally shambolic, politically & bureaucratically obfuscated VH-NGA ditching investigation final report}

Now in an effort to track down the 'unflattering comments' that so offended Dr (BASR) Ghost-Who-Walks, I raided the UP archives based on the timing and this is (much to my amusement..) was what I discovered: Air North Brasilia Crash in Darwin (Merged) #446

Without this diverging into a mixture vs closed throttle vs Flight idle vs zero thrust debate has anyone noticed the gradual decay of the quality of investigation reports coming out of the ATSB?

Besides the Hempel Inquest, where the ATSB appears to have abrogated all responsibility to investigate at all, the ATSB report into the Brasilia accident in Darwin is nothing short of totally spare in its conclusions!

There also appears to be no 'Safety Recommendations' generated from a training accident that I think we could have all learnt a lot more from.

Take a look at a couple of extracts from the report:

Quote:
Terminology used in training and checking
The operator’s documentation did not contain any specific terminology for discontinuing a manoeuvre, but did provide clear instruction as to how control of an aircraft was to be changed between crew members.
To take over control from the pilot flying, or for the pilot flying to relinquish control to the other pilot in a multi-crew aircraft, very specific terminology was used. To avoid any confusion as to which pilot was manipulating the controls, the operator’s General Policy and Procedures Manual, section 4.7.2.2 Crew Communication - Handing Over and Taking Over stated:
The process of handing over control of the aircraft shall always be conducted in a positive manner. To minimise confusion or operational risk, the following terminology shall be used.
To assume control, the pilot monitoring shall call "taking over". To relinquish control, the pilot flying shall call "handing over".
Control of the aircraft cannot be handed over until the pilot monitoring has called "taking over"...
The term ‘disengage’ that was used by the PIC during this simulated engine failure was not standard phraseology. Other EMB-120 pilots reported that they had never heard the term ‘disengage’ used for any action other than deselecting the autopilot/yaw damper and had never heard it used to discontinue a manoeuvre.
They also reported that if a training or check pilot decided to discontinue a simulated engine failure procedure, they would expect that check pilot to restore power to the ‘failed’ engine. Alternately, if the training or check pilot wanted to assume control of the aircraft, they would expect to hear the term ‘taking over’.

Which is pretty basic stuff in a multi-crew aircraft....and then in regards to the Yaw Damper....

Quote:
The operator’s flight operations manual for the EMB-120 stated that the yaw damper was not to be used for takeoff or landing, and that the minimum speed for its use during one engine inoperative (OEI) flight was 120 kts indicated airspeed (KIAS).

.....and then more in relation to the apparent Yaw Damper activation...

Quote:
The use of the yaw damper during asymmetric flight was introduced to the simulator testing following consideration of the cockpit voice recording references to the PIC’s command ‘disengage’ and the pilot under check’s response, ‘yeah, disengaging’. It was assumed that the reference was to the yaw damper and not the autopilot because the chime that sounds when the autopilot was disengaged was not heard on the CVR recording. Additionally, the simulator instructor reported having previously observed pilots engage the yaw damper during simulated engine failures in the EMB-120 in response to pilots ‘overcontrolling’ rudder and aileron following a simulated engine failure.

All of the above is all good factual investigative methodology a lot of which points to a number of operational issues (company SOPs etc) and regulator oversight issues....right?? Wrong, take a look at the first paragraph of the ATSB conclusion.

Quote:
No organisational or systemic issues that might adversely affect the future safety of aviation operations were identified as a result of this investigation.

Maybe this conclusion is a result of the regulator putting in place the Mandatory Simulator program and subsequent NPRM leading to the current NFRM, but does it excuse glossing over what was a particularly significant training accident event that, although tragic, we could all have learnt from!

ps ....and what gives with the no 'Safety Recommendations' issued!

http://www.atsb.gov.au/media/3546615/ao-2010-019.pdf

With "K" in tow, the discussion went on down the page:

Now I'm curious

---

I find I am once again forced to read between the lines of an ATSB report. Technically it's spot on; for example, reading the time line analysis, there is a temptation to question the rudder v aileron input, however this is clearly resolved in the computer simulation graphics. Not having operated a Braz – there are a couple of points of interest which perhaps can be explained by someone who has.
Disengage ?? –could this refer to the Flight Director or is it the Yaw Damper ?. I note the AFM mentions –(paraphrased) FD Before take off (SET), expanded to PF select GA and check 7° pitch up; and, that the AP or YD may not be engaged during TOFF and LAND manoeuvres.

Has it been SOP for the PF to engage the YD as part of an EFATO or was this a recent innovation ?.

The V1, Vr and V2, V2 +10, etc. schedule. The AFM seems to be clear about the speed schedule and the acceleration to V2 +, then flaps up then Vfs (paraphrased). There appears to be a deliberate reduction from V2 + 4 (at – 23 seconds) to V2 (at -20.7 seconds). Is this a norm for the type or a new innovation ?.

Is the un monitored management of the OE, the over torque (124%) and the corresponding rudder/aileron excursions normal for the airborne exercise being conducted ?.

It is suggested by the ATSB final analysis that the BASI recommendations made after an investigation into the Flight Idle v Zero thrust (auto feather) scenario have been ignored. There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

P.S. Categorically not having a pot shot at the crew, the company or the simulator. Just seeking a satisfactory explanation of why and how this 'abnormal' chain of events occurred. If this was a new ME instructor and an initial twin conversion, perhaps this event may have occurred, but it wasn't – was it.

   
Which I followed with:

Quote:
It is noteworthy that simulator based training had been recently introduced; and, conversely that Air North have safely, successfully conducted many 'in flight' simulated failures prior to the introduction of 'simulator' techniques. It is of concern that several things occurred which should give a check pilot the screaming heebie jeebies, airborne.

Perhaps we could ask of the ATSB to investigate 'in depth' the contributing factors to this situation occurring. We have the almost self evident facts of the accident, we have the why, but maybe it would be nice to know the wherefores.

A lot of what was covered in the ATSB report touched on the areas of operational concern and hinted to several differences in history where the Check Pilot had started to diverge from his 'norm'. This quote from page 54 of the report is significant:

Quote:
Two of the pilots who were recently assessed by the PIC reported that he selected flight idle (zero torque) to simulate an engine failure after takeoff in their check flights. It was possible that the PIC had decided to deviate from the operator’s approved procedure in order to test the recognition by the candidate of the additional failure of the autofeather, before setting zero thrust.

 
However it isn't clear whether this 'divergence' from his 'norm' started after he had been to the simulator or before. If it was after then one may suggest that he was operating in a 'simulator induced complacency' manner i.e. it was proven that Flight idle (aircraft) or 'Autofeather Failed' engine failure (simulator) could be successfully recovered from while conducting a V1 cut.

This also appears to have been an area of concern for the regulator, as they used this accident as an example in Annex A of the NFRM for Mandatory Simulator, see here:

Quote:
From CASA NFRM Mandatory Simulator training Annex A:

COMMENT 1.2
Some respondents proposed adding wording to allow training and checking to occur in the aircraft provided the exercise had been conducted by all pilots in a simulator in the preceding 12 months.
CASA Response
CASA is firmly of the view that where a qualified STD is available for aircraft of this size, this should be used for all training and checking activities. The ATSB has reported that the training captain of the aircraft involved in an accident in Darwin in March 2010 had undergone training and checking in a flight simulator, however the actions by the training captain in simulating an engine failure in the actual aircraft during the accident flight was not consistent with the training received during the simulator course. This suggests that doing one session of training and one check per year in an STD (with the subsequent session/check in an actual aircraft) does not satisfactorily address the risk of conducting non-normal exercises in an actual aircraft.

If the Check Captain was inducing this scenario (FI V1 cuts) prior to having gone to the simulator, whereas previously he always only induced a Zero Thrust EFATO scenario, then there must have been input from somewhere/someone to change him to suddenly start breaching the company T&C SOPs??

As 'K' suggests there has been many takes, ambiguity and debate..etc..etc..on the regulatory requirements of CAO 40.1.0:

Quote:
There is much documented proof that CASA have been enforcing 'black letter' CAO 40.1 requirements which conflict with both the AFM (see CAR 138) and a common sense approach to airborne EFATO exercises.

Maybe there is an element of rogue FOI's, that lack the necessary industry experience, that insist on adhering to the letter of the law in CAO 40.1.0. Instead of applying practical safeguards and risk management to high risk training and checking scenarios!!

 
So am I offended that 'his nibs' Dr W#*ker believes that I have no idea about what an "..organisational issue actually is, and when it is, or is not important.?"  - Not on your life I luv it... 


MTF...P2