[Peetwo]

Strange dissonance in the Hooded Canary's coop? - Part II

References:

1)

...There is also the fact that the Wichita accident was not even included as a 'related occurrence'. This apparently was because it did not fit the ATSB hypothesis that the sole cause of the DFO accident was the pilot Max Quartermain's lack of checklist discipline which led to him not identifying that the rudder trim was fully deflected to the left prior to take off - UDB!  

Okay, even with the total lack of physical evidence/proof that this was the case, if we take the examples used to paint the commonality in lack of 'checklist discipline' causal to these occurrences, why then is not the classic accident for these type of human factor pilot error and lack of SOP discipline included in the accident report related occurrence list? Of course I am referring to, the much publicised and commonly referred to by a multitude of AAI Human factors experts, the Runway Overrun During Rejected Takeoff of G-IV - https://www.ntsb.gov/investigations/Acci...R1503.aspx - on May 31 2014?

Even the CASA Flying Safety publication did an article on this occurrence: https://www.flightsafetyaustralia.com/20...nto-error/

THE NTSB SAID, ‘ALTHOUGH ONE OF THE PILOTS COULD HAVE COMPLETED ONE OR MORE OF THESE CHECKLISTS SILENTLY, THE PILOTS DID NOT DISCUSS OR CALL FOR ANY OF THESE CHECKLISTS, EXECUTE ANY OF THE CHECKLIST ITEMS USING STANDARD VERBAL CALLOUTS, OR VERBALLY ACKNOWLEDGE THE COMPLETION OF ANY OF THESE CHECKLISTS.’

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Also of interest: .... a few terse words revealed the immediate cause of the crash.


At 21.39.59 the pilot said, ‘Steer lock is on,’ a remark he repeated six more times in the remaining 20 seconds of the flight. Fourteen seconds later he said, ‘I can’t stop it’.

There was no other discussion of the situation and the only other words before the recording stops were one of the flight crew saying, ‘Oh no, no’ as the aircraft sped towards the ravine that would trap it. Fire broke out ‘almost instantaneously’, in the words of a witness...

   
 I can only assume that the ATSB regarded the GIV Massachusetts accident as not relevant because it was a multi-crew jet accident and not a single pilot B200 or equivalent turboprop accident? In other words it did not again fit the Hooded Canary's singular causal slice of Swiss cheese. Which is a pity because there is much to take away from the GIV prang especially under the safety recommendation part of the report: https://www.ntsb.gov/investigations/Acci...c=A-15-034

...The NTSB determines that the probable cause of this accident was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification.

Recommendation: TO THE NATIONAL BUSINESS AVIATION ASSOCIATION: Work with existing business aviation flight operational quality assurance groups, such as the Corporate Flight Operational Quality Assurance Centerline Steering Committee, to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members as part of your data-driven safety agenda for business aviation.

 
Ah yes, unless it is absolutely positively PC and won't have any blow back for the miniscule, the Hooded Canary's flock, unlike the rest of the 1st world AAI organisations, doesn't do safety recommendations and I guess that includes reading the ones from peer organisations like the NTSB? - FDS!   
 

2)

...The Essendon crash deserved the ATSB’s very best efforts; it could have been a serious disaster, with magnified ramifications. Yet it was quickly concluded that it was all pilot error, nothing to see and the ATSB would concentrate on whether the building measured up to ‘Black letter’ approval. For starters, ATSB are not in the ‘airspace game’ nor are they forensic legal experts on ‘approval’ to build, particularly in light of the convoluted processes used. So why was the aircraft and pilot quickly dismissed in favour of some half-baked ‘investigation into what Hood claims was a ‘life-saving’ building. It’s bollocks – ATSB’s job is to tell us, as best they can, from the charred remains – why this aircraft crashed and claimed five lives; difficult as that maybe... 

&..from this Airports thread post: A duty of care. - Part II

3)

Patrick Hatch article: ..The Australian Transport Safety Bureau found that pilot error was to blame, but while looking into the crash, decided to launch a separate investigation into how the DFO complex was approved "from an aviation safety perspective".

That probe is nearing completion, with its final report currently out for review by the parties involved ahead of its public release...

A quick check from the ATSB aviation investigation webpage does seem to indicate a recent update to the DFO approval process investigation (AO-2018-010: https://www.atsb.gov.au/publications/inv...-2018-010/

Investigation number: AI-2018-010
Status: Active  Investigation in progress
Phase: Final report: External review

Summary

On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.

The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.

General details
Date: 21 February 2017
Investigation status: Active
Investigation level: Complex
Location   (show map): Essendon Airport, Bulla Road Precinct Retail Outlet Centre

Investigation phase:
Final report: External review
State: Victoria
Report status: Pending
Expected completion: 1st Quarter 2019

Last update 11 January 2019

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Final report: External review phase

To check factual accuracy and ensure natural justice, Directly Involved Parties (DIPs) are given the opportunity to comment on the final report before it is approved to ensure their input has been accurately reflected.

DIPs are individuals or organisations outside the ATSB who possess direct knowledge of the circumstances surrounding the incident or accident. DIPs can only comment on the factual accuracy of an investigation, not its analysis and findings.

This process is consistent with international transport safety investigation conventions, including those published by the International Civil Aviation Organization, International Maritime Organization as well as the Transport Safety Investigation Act 2003. DIPs are provided from five to 28 days to provide their comment and present evidence in support of their comments. This timeframe can be extended to allow DIPs based overseas to provide comment.

Feedback from the DIPs could prompt an investigation to return to the evidence collection, examination and analysis, and report drafting phases of an investigation.

Final report: Approval phase
Following the DIPs process, the report is approved by management before being sent to the ATSB Commission for final approval. Once approved, the final report is prepared for publication and dissemination.

Although the expected completion is quoted as being in the 1st quarter of 2019, to suggest that the investigation is nearing completion is  laughable when you consider the investigation into the VARA ATR broken tail accident has been stuck in the external review process for nearly 2 years (see - https://www.atsb.gov.au/publications/inv...-2014-032/ ). Even then the final report still has to be approved by the ATSB management, PC'd by the commissioners and again run by the DIPs before finally being released for industry and general public dissemination..

Final report: Dissemination phase
Once an ATSB report is approved, it is released to DIPs prior to its public release and approved safety issues and recommendations are formally communicated to the relevant parties. The report is then released publicly on the ATSB website and communicated on social media channels. The progress of safety action to address ATSB recommendations is tracked and communicated, on an ongoing basis, via the ATSB website.

It is important to note that the ATSB does not wait until its investigations are complete or the final report is published to address critical safety issues. If a critical safety issue is identified during the course of an investigation, it is brought to the attention of the relevant parties immediately so that safety action can be taken.

When you read that last statement in italics and then reflect on how the Hooded Canary's ATSB completely glossed over the significance of the DFO complex to the causal chain of the accident, to the point where they even had the mendacity to suggest the building may have been instrumental in saving lives.

“In the absence of that building, the aircraft’s flight path would probably have resulted in an uncontrolled collision with a busy freeway, with the potential for increased ground casualties,” the report said. 

It is then very hard to believe the veracity and intent of this investigation to potentially mitigate safety risk. Especially when you consider that despite 60+ years of worldwide experience in mitigating public safety risk with inappropriate urban development encroachment around airports, the Hooded Canary's ATSB apparently and bizarrely can't even see the wood for the trees...  

And it is not like the ATSB can't say they weren't warned:

They even had an opportunity in the context of another ATSB investigation which was ironically entitled Building approval process for structures in the vicinity of Australian airports: references - And the YMEN DFO accident fairy tale grows & https://www.atsb.gov.au/media/5774258/ai...-final.pdf :

The ATSB carried out an investigation four years later in 2013 into the procedures of these decision-making processes. This was done as a response to a REPCON report received in September 2012(P2 comment - bizarrely the ATSB REPCON database doesn't appear to go back to 2012??) expressing concerns a proper safety case was not conducted on the proposal. The ATSB’s Final Report concluded that whilst the procedure was compliant with the Airports Act 1996 and the Regulations, it “did not require the application of risk management principles to the Department’s consideration”. This was highlighted as a safety issue.

 
Which again brings me back to the QON that I then asked in the context of that post:

The question there is when was this significant safety issue 1st identified? Another question is - why wasn't the 2013 investigation and final report referred to in either the YMEN DFO accident final report; or in the (AI-2018-010) above summary??   

Note that even back then the ATSB completely ignores the far greater 60+ year safety issue of public safety zones around airports...  

Yet they do intimate that it is the responsibility of both the Minister, his Dept and agencies to effectively mitigate aviation safety risk around airports through the proper ICAO Annex 19 endorsed Australian State Safety Program.


Hmm...MTF me thinks - P2