[Peetwo]

Update: ATSB PC accident investigation AO-2014-032

Remember when High Viz Hoody was singing like a Canary at the Drone Wars inquiry in regards to the 3.5 year VARA ATR busted tail investigation? Here is a reminder -  

Well there is still no sign of the 3rd interim report - see HERE. However there was some progress recorded on the ATR safety recommendation (AO-2014-032-SI-02) that occurred prior to the singing Canary Hoody's proclamation at the 29 Aug DW1 public hearing..

Recommendation


Action organisation: ATR

Action number: AO-2014-032-SR-014

Date: 05 May 2017

Action status: Released


The ATSB recommends that ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.


Correspondence


Date received: 11 August 2017

Response from: ATR  

Action status: Monitor

Response text:

In an update provided on 11 August 2017, ATR briefed the ATSB on the results of:
•flight testing to determine the pilot input profile following an intentional pitch disconnect
•a comparison of the dynamic model computation against flight test data
•the analysis of the pitch system jamming cases.

The flight testing identified a consistent post-disconnect pilot input profile for use in the dynamic model and indicated that there was no discernible difference in the profile across the tested speed range. Also, the results from the dynamic (engineering) model compared well with the flight test results, indicating that the dynamic model satisfactorily represents the aircraft behaviour during an in-flight pitch disconnect.

ATR applied the dynamic model to assess the effect of an in-flight pitch disconnect at the maximum operating speed (VMO) in two representative pitch system jamming cases. The results indicate that there is a margin between the peak elevator deflection during the pitch disconnect and the deflections required to generate the ultimate loads, at VMO.


ATSB response date: 05 September 2017

ATSB response:

The ATSB accepts that ATR has completed part of the engineering assessment of the transient elevator deflections following an in-flight pitch disconnect.

The ATSB notes that to date, we have only been provided with basic analysis results and that those results have been presented to EASA in a similar timeframe. The ATSB has not yet been provided with documentation showing an independently reviewed engineering assessment, but acknowledges that this would not be practical until the engineering assessment has been completed.

The ATSB also notes that the following engineering analyses will be required to meet the intent of this Safety Recommendation:
•Cases of inadvertent pitch disconnect events from dual control inputs
•Evaluation of the effects of variation of the pitch channel stiffness in the fleet

The ATSB will continue to monitor the work carried out by ATR in response to the identified safety issue.

Then about a week ago the following new investigation was initiated (note new investigation No.) that was bizarrely co-joined to the ongoing ATR broken tail investigation -

Case study: implementation and oversight of an airline's safety management system during rapid expansion
 
Investigation number: AO-2017-100
Investigation status: Active
 

• Tab - Summary
  

Summary
As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
• reviewing other investigations and references where similar themes have been explored.
  

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General details

Date: 19 October 2017
 
Investigation status: Active
 
Investigation type: Safety Issue Investigation
 
Location   (show map): 47km WSW, Sydney 
 
State: New South Wales
 
Occurrence class: Technical
 
Occurrence category: Other
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: October 2018 
 
 

Last update 19 October 2017

Hmmm....why does the summary and ToR for this case study investigation sound so familiar -


MTF...P2

P2 OBS: This is an investigation within an investigation that has some very real parallels to the PelAir cover-up re-investigation (examining 'organisational influences').  Yet the PelAir ongoing investigation still carries the original investigation No. - Why?