[Peetwo]

Safety loops, trends & disconnections?

Kharon: "..So to the 717 crew and their wee problems; how deep do we dig?  Is the fix presented adequate to task? Has the ATSB done enough to cure the problem?  Can this be classed as an ‘operational’ matter?   The rational way to answer is to examine one factor only – can this happen again?  The answer to that is a resounding absolutely. The loop remains open.."

Nail on head "K" but this is not an isolated occurrence aberration, these are well documented repetitive operational safety issues. Yet the ATSB don't seem capable of even joining their own dots, which perhaps is best reflected in the fact that this occurrence was 'desktop' investigated and discretely hidden away in the latest ATSB SIB - WTD..

IMO if the ATSB had of join some of their own dots, they would have spotted a growing trend of similar incidents/accidents that potentially point to similar/identical contributory factors.

Let me explain...

If you go to the ATSB 'Safety Watch' (or safety issue trend page) webpage, you will see there is one safety concern photo labelled 'Data Input errors':

[/url][url=http://www.atsb.gov.au/safetywatch/safety-around-aeros/]Data input errors
Safety concern
There have been numerous accidents worldwide that were the result of simple human errors in data calculation or entry.

Data errors—such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded—happen for many different reasons.

The consequences of these sorts of errors can range from aborted take-offs through to collisions with the ground. Errors can occur irrespective of pilot experience, operator, aircraft type, location and take-off performance calculation method.
 

 
What the ATSB is doing
As part of its investigation into an Airbus A340 tailstrike and runway overrun at Melbourne Airport in March 2009, the ATSB acknowledged the European Aviation Safety Agency (EASA) action in assisting setting up a working group with the European Organisation for Civil Aviation Equipment (EUROCAE) to study the feasibility of take-off performance monitoring systems and developing an equipment standard. The ATSB also made a recommendation to the US Federal Aviation Administration (FAA) to address the existing standard that did not provide flight crews with a means to detect degraded take-off acceleration. The FAA has subsequently joined EASA as a member of the working group and, given this safety action, the ATSB has closed that recommendation.

In recognition of the hazards posed by data entry errors, the ATSB will continue to monitor output from the EUROCAE take-off performance monitoring working group and any associated developments that may assist in mitigating this risk.

What can you do?
While no one is immune from data input errors, risk can be significantly reduced through effective management and systems. Good communication and independent cross-checks between pilots, effective operating procedures, improved aircraft automation systems and software design, and clear and complete flight documentation will all help prevent or uncover data entry errors.

The ATSB advises operators to consider all the possible errors that could be introduced and then determine if the procedures in place will prevent these errors from occurring, or will provide an opportunity to detect them.

More information
An ATSB safety research report, Take-off performance calculation and entry errors: A global perspective, examines Australian and international occurrences between 1 January 1989 and 30 June 2009 that involved the calculation and entry of erroneous take-off data.
The following investigation reports also provide useful lessons on the potential dangers of data input errors:

• An Airbus A340-541 tailstrike and runway overrun that occurred at Melbourne Airport on 20 March 2009
  
• An operational event involving an Airbus A380 that occurred at Los Angeles International Airport on 8 October 2011
  

Useful international reports include:

• A study by the US Navy/NASA Ames Research Center: Cockpit interruptions and distractions: A line observation study
  
• A NASA research publication, Performance Data Errors in Air Carrier Operations: Causes and Countermeasures
  

Related: SafetyWatch
 

     
 Because this safety concern is still highlighted on the bureau 'Safety Watch' page, would suggest that this is still a very real ongoing safety concern that is yet to be properly risk mitigated.

The focal occurrence that lead to this ATSB 'safety watch' initiative was of course the Emirates A340 T/O occurrence out of YMML - Airbus A340 tailstrike and runway overrun at Melbourne Airport in March 2009. If you go down through the various links in the safety watch initiative you have to commend the ATSB for their efforts to address this safety concern. These proactive actions included a rare 'safety recommendation' addressed to the FAA, who responded respectively, appropriately and timely:

Date received: 19 December 2011

Response from: United States Federal Aviation Administration

Response text:

During the investigation, the ATSB sought an understanding from the United States Federal Aviation Administration (FAA) of whether the FAA was contemplating work similar to that by EASA to develop a standard to guide the development in the US of take-off performance monitoring systems. On 6 December 2011 the FAA advised that:

…the FAA has entertained this idea before, notably, in the aftermath of the Air Florida accident here in Washington, DC, and has found the idea of these systems, with all of their inherent complexity to be more problematical than reliance on adequate airmanship. That has been the FAA position in the past. I'm sure the FAA would be happy to entertain any recommendation to re-visit the issue in the light of new information or ideas.

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...Previous unexpectedly poor takeoff acceleration events led to the 1987 SAE Aeronautical Standard for takeoff performance monitoring (TOPM) systems. Because adequate technology and equipment were not available at that time, no systems were completed, and the standard was never invoked.  

With advances in technology and equipment, the European Organisation for Civil Aviation Equipment (EUROCAE) convened a working group to study the feasibility of developing standards for TOPM systems. The group is expected to deliver its first report in March 2013.  We intend to work with the government and industry team to define modern standards for designing and using TOPM systems.

The ATSB report noted that the first contributor to the subject accident was a human data entry error in the first digit of the airplane’s takeoff weight which caused gross discrepancies in takeoff calculations and expected performance. To address this hazard, we issued policy covering weight entry methods in flight management systems that are intended to reduce exposure to the particular error that initiated the Emirates accident sequence. Future systems will include features to assist pilots during flight planning that would reduce the likelihood of hazardous preflight errors. The features will perform automatic checks on each weight component and calculation, and will alert the crew to errors. TOPM systems, if available, would provide another layer of safety and error detection...

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ATSB response:

The ATSB acknowledges that the FAA is collaboratively working towards addressing this safety issue and will continue to monitor the progress of the safety actions.

Okay so all good responsible 'adult' stuff and a perfect example on how the system is supposed to work..

The other proactive ATSB action to come from the Emirates occurrence was the completion of the research paper titled - Take-off performance calculation and entry errors: A global perspective 

Which highlighted that this was a multi-faceted safety issue that even the former CC, & MH370 super sleuth, Beaker had to admit would not be easily addressed: No single fix for aircraft take-off errors: ATSB report

Spot the disconnect...

However what I found most interesting, in the preamble to that report, was the breakdown of figures for the ATSB identified contributory factors that included some of Kharon's more considered causal issues to the B717 YSCB incident:

A review of the international and Australian occurrences showed that these types of errors have many different origins; with crew actions involving the wrong figure being used, data entered incorrectly, data not being updated, and data being excluded. Furthermore, a range of systems and devices have been involved in these errors, including performance documentation, laptop computers, the flight management computer, and the aircraft communications addressing and reporting systems. The consequences of these errors also ranged from a noticeable reduction in the aircraft's performance during the takeoff, to the aircraft being destroyed and loss of life.

The most common contributing safety factor identified related to crew actions (39 per cent), including monitoring and checking, assessing and planning, and the use of aircraft equipment. This was followed by absent or inadequate risk controls (31 per cent), mostly centred on poor procedures, non-optimally designed aircraft automation systems, inappropriately designed or unavailable reference materials, and inadequate crew management practices and training. Common local conditions (27 per cent) involved inadequate task experience or recency, time pressures, distractions and incorrect task information.

A 27% 'hole in the cheese' I would have thought, should be considered worthy of further investigative exploration??

However that was in January 2011 and since that time there would appear to have been a stalling of any further proactive actions to address the other IMO significant safety factors...

Meanwhile these latent safety issues are possibly reoccurring in similar domestic incidents but due to the strange prioritisation of resources (& a continued desire to be PC by the ATSB), these serious, trend identified occurrences are yet to be completed...

Example (with reference to 'Closing the safety loop' thread post - TICK TOCK goes the Miniscule clock??) note the last update to AO-2015-139 :

Updated: 23 August 2016

Completion of the draft investigation report has been delayed due to competing team member priorities and workload, and to allow additional investigative work to be finalised.

This additional work includes:

• obtaining and consolidating additional evidence
  
• analysis of evidence held and the development and test of investigation findings.
  

When complete, the draft report will be released to directly involved parties (DIP) for comment and on the factual accuracy of the draft report. Feedback from those parties over the 28-day DIP period will be considered for inclusion in the final investigation report.

Hmm..no further comment required - over to you Ferryman...
MTF...P2