[Peetwo]

P2 - Off another discarded & forgotten UP thread, that was IMO of excellent value i.e. ATSB reports, are two posts of relevance from Old Akro

While I'm raiding that UP thread I thought it worthwhile regurgitating 4 posts off page 2 that partly explains the slide of the bureau. It is for mine extremely sad that the BASI/ATSB has gone from a small, poorly resourced air safety watchdog that used to punch well above its weight and was held in high esteem throughout the aviation safety fraternity worldwide; to an insipid non-independent AAI that panders to the political/commercial interests of various DIPs to higher profile investigations, while playing submissive lapdog to the big R regulator behemoth CASA...   

Centaurus

Not just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers  

Interesting observation re the vast experience needed nowadays to write a report. I am sure it has changed now in the RAAF but during my time there in another era, accident investigations were over and done with within one month to three months.

Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could.

One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around.

Old Akro

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.  

It takes years of experience to apply a wind vector as a tailwind before & after a 180 deg turn? Or produce different wording for the transcripts of radio calls between the initial, preliminary and final reports?

Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review.

Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports.

This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k.

Kharon

Longish post warning

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OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa.

 
It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).

"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.

The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.

I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.

When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.

It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.  

The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..

Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did.

Senator FAWCETT: Does this report make any recommendations for improvements?

Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.

Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.  I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions.... 

Again I consider it important to reflect on this post & indeed that old but not totally forgotten excellent UP thread - ATSB reports.

This week the ATSB released another Final Report - AO-2013-163 - of a lesser known GA fatal accident that occurred on 23 September 2013 in Hamilton Victoria.

From Oz Flying:

The burnt wreckage of C182 VH-AUT after the aircraft collided with the ground. (ATSB)

ATSB releases Investigation Report into Hamilton Crash
07 May 2015

The Australian Transport Safety Bureau (ATSB) has released its investigation report into the fatal crash of a Cessna 182 at Hamilton in Victoria.

The pilot of VH-AUT was conducting night circuits on 23 September 2013 as part of an airline cadetship when the aircraft crashed after executing a go-around.

"The ATSB found that following an aborted landing during circuit training in dark night conditions, the solo student pilot lost control of the aircraft, resulting in a collision with terrain," the investigation report states. "There was insufficient evidence to determine the reason for the loss of control.

"The student pilot’s post-mortem examination identified a cardiac condition capable of causing incapacitation and their medical history included another condition that, if having effect at the time, had the potential to have contributed to the development of the accident. The Civil Aviation Safety Authority (CASA) was unaware of either condition."
In addition, the ATSB found the C182's flaps were fully extended at impact, which was not consistent with either the operator’s or manufacturer’s procedures for a go-around. However, the investigators were able to determine how or if the flaps contributed to the crash.

Other factors considered were the pilot's past history of Attention Deficit Hyperactivity Disorder (ADHD) and the potential for spatial disorientation.

Having read through this report I cannot but feel that the ATSB has missed yet another golden opportunity to pass on some significant safety lessons from this tragic accident...

Maybe to the further shock & horror of Lefty off the UP.. ..I noticed that Centaurus (from above) has started a thread on this ATSB report. His excellent post more than adequately (& a whole lot more) reflects my sentiments on this Final Report... :

ATSB report on fatal C182 Go-Around at night

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Investigation: AO-2013-163 - Loss of control and collision with terrain involving Cessna 182 VH-AUT, Hamilton Airport, VIC on 23 September 2013

In Cessna singles, a very low altitude go-around with full flap is a demanding exercise particularly with the strong pitch up that occurs at full throttle. To conduct the exercise under the hood or simulated IMC takes very sound instrument flying skills. On a dark night with no visible horizon, even an experienced pilot would need to be very careful during the initial change to climbing attitude and the change of trim that occurs as flaps are retracted to an intermediate setting and then up.

The nose down trim that occurs as the flaps retract needs to be countered lest the aircraft goes from the initial climb into a gentle descent because of poor instrument cross-reference by the pilot. This manoeuvre needs to be practiced under the hood to simulate loss of forward visibility such as rain or dark night conditions. It is a highly critical manoeuvre on instruments and no student should be sent solo until he has done several runway level go-arounds on instruments and judged to be perfectly competent.

Most pilots will recall the advice by their instructor on being sent for their first solo. It is usually something like "When in any doubt do not hesitate to go-around". That applies whether it is first daylight solo as well as first night solo. Most flying school instructors teach the go-around at around 200 feet and it is probable that very few teach go-arounds from the flare or during the float which is the most critical point with everything hanging out, speed bleeding and maybe even the first few bleats of the stall warning.

This runway level go-around is demanding but needs to be taught as should the recovery and landing ahead on the remaining length should a balloon or high hold off occur. A go-around from several bounces gets increasingly dangerous as speed is close to the stall. for that reason students need to be confident and competent to go-around again from a bounce before first solo day or night as well as equally competent to recover from a bounced landing and re-landing straight ahead.

Disregarding for the moment the ATSB medical report of the students heart condition, I believe ATSB missed a good opportunity to discuss the traps that can occur should a pilot have reason to go-around at very low altitude at night. Spatial disorientation is only one factor. A vitally important factor is the skill of the pilot and how he was taught by his various instructors.

Often, instructors do not adhere to the recommendations published in the manufacturer's AFM or Pilot handbook. Sometimes training schools publish their own procedures rather than the manufacturer's procedures. Physical handling of the go-around especially with regards to trim changes with flaps and the pitch up that occurs during a low speed full flap go-around need to be thoroughly understood by students One of the most effective teaching techniques is by doing the go-arounds at a safe height under the hood in simulated IMC/dark night.

In another era I was a RAAF QFI doing recurrent night flying training in a Lincoln bomber at Townsville on a experienced former wartime bomber pilot. He was much more experienced than me but out of currency on night circuits. After several touch and go landings on Townsville Runway 01, he was instructed to turn right 30 degrees after take off to track over the water east of Magnetic island. Apart from a few lights from houses at Magnetic island it was dark and we were on instruments.

At 800 feet after take off , the right turn was commenced and flap retraction took place. The QFI had no flight instruments in front of him (the Lincoln was designed for single pilot operation) and he had to lean to the left to monitor the pilots instruments which gave significant parallax error problems. As the flaps started to slowly retract from the take off setting, there was the usual nose-down change of trim. The pilot who was fully on instruments because of the dark night and no visible horizon, failed to counter the nose down change of trim and allowed the Lincoln to gently descend with the VSI changing from a 500fpm rate of climb at 5 degrees nose up to 2-300 fpm descent with his AH just below the horizon.

The radio altimeter showed a steady slow descent and it was obvious that the experienced bomber pilot was slow in his instrument scan as he said nothing. At around 500 ft radio altitude above the sea, I called and said "Watch your VSI "Sir". He was a squadron leader and therefore a "Sir" as I was junior in rank even though as QFI, I was captain of the aircraft.

With a muttered oath of surprise, the pilot swiftly pulled back on the control column arresting the descent and we resumed the climb. Nothing was said between us. it didn't have to be as it was clear that he would have allowed the aircraft to descend slowly into the sea. As mentioned earlier he was not current at night and not current on instrument flying which is why we were flying as dual instruction that Townsville night.

If a highly experienced pilot like the squadron leader had troubles on a night departure one can imagine the difficulty a Cessna student pilot at night doing a late go-around with full flap must have had..

  
Top stuff Centaurus...

Definitely MTF..P2

Ps This is not a good look for AVMED  :  

...A CASA aviation medical specialist advised that the standard aviation medical examination procedure for a person of the pilot’s age may not have detected the condition...

...For reasons that could not be conclusively established, CASA was unaware of the student pilot's prior treatment for ADHD. As a result, CASA was unable to determine whether the pilot was free of symptoms prior to beginning their airline pilot cadet scheme and consider any ongoing surveillance of the pilot.

Pooshambolic & Co were probably too busy chasing life threatening CVD Wannabes away from the industry...