[Peetwo]

Has the worm turned on 'organisational factors' and O&O'd investigations?

Off search 4 IP yesterday : Update: ATSB PC accident investigation AO-2014-032

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.
  

Then yesterday as reported by WA Today (note my bolding):

October 25 2017 - 12:12PM

Perth Skyshow plane crash: ATSB probes other airshow disasters, safety standards

• [/url]David Allan-Petale
  [url=http://www.watoday.com.au/wa-news/by/David-Allan-Petale-gxi4aw]
  

The investigation into what caused a fatal plane crash on Australia Day in Perth has analysed other disasters including the 2015 Shoreham Airshow crash in the UK that killed 11 people.

Perth pilot Peter Lynch and his passenger and partner Endah Cakrawati died when the Grumman G-73 amphibious aircraft crashed into the Swan River during the City of Perth's annual Skyworks event on Australia Day.
 


The Grumman sea plane crashed into the Swan River on Australia Day, killing its two occupants. Photo: Mike Graham
 
The seaplane nose-dived into the water about 5pm in a plunge the Australian Transport Safety Bureau said was "consistent with an aerodynamic stall".

The plane broke on impact in front of hundreds of horrified witnesses gathered along the Swan River foreshore to watch an air display Mr Lynch was part of in the lead up to the fireworks show.
 
In a statement to WAtoday, the Civil Aviation Safety Authority said Mr Lynch's aircraft was operating as part of an approved air display, which was given special permission to operate.

Immediately after the crash, the ATSB began an investigation and is now probing the "planning, approval and oversight of the air display", sifting through years of data for the Perth event and other air displays across Australia, as well as "procedures and guidance relating to Civil Aviation Safety Authority (CASA)‑authorised air displays".

As part of its inquiry, the ATSB analysed the Shoreham Airshow crash, in which an ex-military Hawker Hunter jet aircraft failed to complete a loop manouevre and crashed into a highway, killing 11 people on the ground and injuring 13, including the pilot.

The final report of a UK investigation into that crash concluded it was caused by pilot error, with the aircraft too low to safely complete the loop.

The Shoreham Airshow crash killed 11 people on the ground. Photo: Nicholas Hair via Twitter @NDH37087  

For the Perth crash, the ATSB had previously said it had "not identified any evidence to indicate that pilot incapacitation or aircraft serviceability were contributing factors to the collision with water".

However, it looked at the Shoreham crash to compare the approval processes and safety regulations for airshows around the world with Australia.


An ATSB image showing the flight path of the plane over the foreshore and river. Photo: ATSB
 
"Preliminary analysis of this information has identified differences in the approval process within CASA, between civil and military (including combined) displays and between Australia and other countries," the ATSB said.

"The ATSB is continuing to analyse this information, to determine whether there are any systemic safety issues in relation to authorised air displays."

The investigation is continuing, with a final report expected to be completed by January 2018.

Maybe wishful thinking but I am beginning to get the impression that someone has read Hoody and the ATSB the riot act on PC'ing and obfuscating systemic regulatory oversight issues in AAI - 

MTF...P2