[Peetwo]

AAI & the implications of bureaucratic O&O

References for the previous (September 2015) BITN thread coverage of the ATSB Hotham 'near collision' Serious Incident AO-2015-108 starting from here:

Them holes are aligning

Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering,  aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...



Courtesy the Oz:

Near miss for planes carrying 18 people  

• by: Matthew Denholm
  
• From: The Australian
  
• September 17, 2015 12:00AM
  

Tasmania Correspondent
Hobart




Too close for comfort. Source: TheAustralian

An “unsafe” close encounter ­between two planes near Mount Hotham Airport in Victoria allegedly placed up to 18 lives at risk, fuelling demands for better use of radar at Australia’s regional airports.  

According to an incident ­report obtained by The Australian, two Beechcraft B200 King Air planes on private charters from different companies — one from Essendon in Melbourne and one from Bankstown in Sydney — were vertically within 300ft (90m) of each other on September 3.

It appeared the Essendon-based pilot, struggling with a faulty GPS in heavy morning cloud and poor weather, did not know where he was and reported being in vastly different locations, varying by up to 20 nautical miles, within a short period of time.
Radar traces of this plane, chartered from small Essendon-based operator Seidler Properties, show an apparently erratic path at times, and that the scheduled 38- minute flight took an hour and 27 minutes.

The Essendon plane came within one nautical mile (1.8km) of the other aircraft and eventually landed at Mount Hotham, in the Victorian Alps northeast of Melbourne, but only after what the report by the other pilot ­described as an “unsafe” approach from the “wrong direction”. There were three other aircraft also en route to the airport at the time.

The report, titled “breakdown of separation”, says passengers on the Essendon-based plane were so shaken they refused to return with the same pilot later that day, ­requiring another to be flown to Mount Hotham to pick them up.

In a report being investigated by the Australian Transport ­Safety Bureau, the pilot of the Bankstown-originating aircraft — a senior pilot at a major charter firm — describes the situation as “not safe”.

He suggests he is making the report not to attack the Essendon-based pilot, but rather to highlight an ongoing risk of tragedy in the absence of a safety back-up in cases of pilot error at uncontrolled regional airports.

“If this event did result in a midair collision, two aircraft would have been destroyed and 18 people would have been killed,” says the Bankstown-originating pilot in the report, sent to the ATSB two days ago.

“As a chief pilot, I am significantly concerned with the breakdown of (aircraft) separation caused by this incident. This is not a standard of operation that I would tolerate from my pilots and I do not accept that his event goes without investigation.

“Two high-performance aircraft with 300ft separation (vertic­ally), within one nautical mile of each other (horizontally), in IMC (instrument meteorological conditions), is not safe.”

The incident has further highlighted the lack of radar control of aircraft to low altitudes at ­regional airports in Australia, which The Australian has documented in the series of articles over the past two months.

In uncontrolled airspace, ­pilots must communicate with each other by radio to ensure they remain safely separated, with no support from an air traffic controller monitoring them on radar or providing co-ordination.

At Mount Hotham, radar-based separation of aircraft ends at 18,000ft, below which pilots must self-separate, despite radar being available to a far lower altit­ude.

Veteran aviator Dick Smith told The Australian the latest Mount Hotham incident highlighted the need to make full use of radar coverage at regional airports to improve safety.

“If they were using the existing radar for control at Mount Hotham, neither of these things (the ­alleged mid-air near collision and subsequent alleged dangerous ­approach) would have happened, because the controller would have told the pilot what was happening,” Mr Smith said.

He said it was particularly frustrating the existing radar was not being used to control aircraft to low altitude at Mount Hotham, given the deaths of three people in a crash there in 2005 and of six people in an accident at Benalla, about 150km from Mount Hotham, in 2004. He believed both crashes could have been averted had radar control close to ground level been provided.

“How many more frightening incidents like this before there are more unnecessary deaths?” Mr Smith said.

He said all that was needed to make use of existing radar for separation control to low altitudes at regional airports was for Airservic­es Australia to provide more training to controllers at its Melbourne and Brisbane radar centres.

Airservices insist the air traffic system is safe and that levels of control around the country are appropriate for local traffic volumes and types.

An ATSB spokesman said the latest Mount Hotham incidents were being investigated.
However, an official statement on the bureau’s website refers only to the “unstable approach” to the runway; not the earlier alleged close encounter. Seidler Properties suggested it was unaware of any investigation and declined to comment.

To think this 'serious incident' may have gone unreported 
How many other similarly serious occurrences have gone unreported (I personally know of a couple) because of fear of retribution or incriminating oneself.

Yesterday in a media briefing our High Viz Chief Commissioner Greg Hood made some bollocks statements in relation to O&O'd ATSB investigations and the stalled 540 day (so far) MT Hotham near miss investigation:

Air safety bodies spoke ‘more than once’ on pilot’s near-miss
Australian Transport Safety Bureau chief commissioner Greg Hood briefs media on the Essendon Airport crash that killed five, including pilot Max Quartermain. Picture: Getty Images


...ATSB chief commissioner Greg Hood denied the agency faced a lack of resources in investigating other incidents which do not result in deaths but which might prevent future fatalities. In the 2015 incident, Max Quartermain was at the controls of a plane heading into a ski resort at Mount Hotham when he experienced difficulties with the GPS, almost hit another aircraft and landed at the wrong end of the runway.

An investigation into the near-miss will not be finalised till May, almost two years after the accident. “It’s more a prioritisation issue,” Mr Hood said.

“We have a means of categorising the transport accidents and serious incidents that we investigate and obviously those that involve multiple fatalities or that have the ability to improve transport safety are those that we prioritise and sometimes that means that others are delayed...

On a visit to the ATSB MT Hotham 'near miss' investigation webpage - see HERE - I note that this incident is still listed as an ATSB defined 'serious incident' (versus an ICAO annex 13 defined 'serious incident'), the differentiation of which is effectively obfuscated within the 10 pages of NDs to Annex 13:

Australia requires reporting of ‘transport safety matters’, which, through definitions
and reporting requirements in the Transport Safety Investigation Act 2003 and Transport
Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of  serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.

  
WTD...

Okay what I think the ATSB notified difference to ICAO Annex 13 on the definition of a 'serious incident' means, is that the ATSB can (read will) effectively abrogate all responsibility to investigate all 'serious incidents' under the spirit, intent and compliance of the Annex...

Therefore the ATSB practice of O&O'ing some potentially DIP sensitive 'serious incident' investigations has become a normalised SOP.

In the case of the MT Hotham 'near miss' investigation the delay can be (& probably will be) excused because the regulator CASA has conducted proactive safety risk mitigation by testing, re-testing and overseeing the proficiency checks of the incident pilot. The ATSB only need say that safety risk was being effectively mitigated.

However it is 'passing strange' that nowhere within the AO-2015-108 investigation webpage does the ATSB indicate that they have identified a 'safety issue' (i.e pilot proficiency) that they have subsequently sent to CASA to be proactively addressed. Nor is there any indication of any form of Annex 13 required 'interim report' on the 1st anniversary of the ATSB defined 'serious incident' investigation...

On the subject of 'interim reports' and Hoody's defined categorisation/prioritisation of 'accidents', I note that in recent days we have quietly, stealthily drifted past the 3rd anniversary date of an ATSB defined 'immediately reportable accident' that had the potential to be the single most worst aviation disaster in Australian aviation history - see HERE or HERE.

ATSB - who the fuck needs them...


MTF...P2