[Peetwo]

Hooded Canary's 2019 O&O investigations - Update.

Given that it is approaching February it should be safe to assume that the Hooded Canary and his minions are all back on deck. Therefore now would be a good time to start trolling through the ATSB Aviation investigation web page records to see where the higher profiled and complex O&O'd investigations are at.

Since it was the last post on here, let's start with the tragic Rossair Conquest training accident. Although the webpage lists a recent update visit - Last update 14 November 2018 -  there does not seem to be any added additional information since the prelim report - see here:  https://www.atsb.gov.au/publications/inv...-2017-057/- and the progress of the investigation is still listed as - Phase: Examination and analysis.

Examination and analysis phase

The cause of a transport safety occurrence or safety issue is often multilayered and complex. ATSB investigators aim to use the collected evidence to build a detailed understanding of the circumstances surrounding a transport safety occurrence or issue.

During this phase, evidence is reviewed and evaluated to determine its relevance, validity, credibility and relationship to other evidence and to the occurrence. ATSB investigators may:

- undertake detailed data analysis
- create simulations and reconstruct events
- examine company, vehicle, government and other records
- examine selected wreckage in the laboratory and test selected components and system
- research scientific literature related to human factors associated with the evidence
- review specialist reports (such as meteorology, component examination, post-mortem report and toxicology reports)
- conduct further interviews, and
- determine the sequence of events.

Examination and analysis requires reviewing complex sets of data, and available evidence can be vague, incomplete and or contradictory. This may prompt the collection of more evidence, which in turn needs to be analysed and examined, potentially adding to the length of an investigation.

Not sure what the hold-up could possibly be but unfortunately it is pretty safe to say that this AAI will pass by the 2nd anniversary of this tragic accident.

..On-site examination of the wreckage and surrounding ground markings indicated that the aircraft impacted terrain in a very steep (almost vertical) nose‑down attitude, and came to rest facing back towards the departure runway...

Note: While the ATSB (for whatever reasons) continues to O&O this accident, I have been informed that there are PAIN associates that are starting to ask serious questions about this accident and in particular what could have caused the aircraft to go from being in stable flight to inverted and diving near vertical from a height of 600ft AMSL.

Ref: Update 09 June 17: Byron Bailey OP.

P9 - Casa DICTATED ‘Blue line’ fever strikes again?  I know, I know, wait for the details; but this new ‘regime’ of stupidity – V2 + 10 or a nice fat sandwich of wriggle room – all gone.  When will they realise the SIM ain’t real.

10 minutes sin bin? – OK - sounds reasonable M’lud; thank you – bow – exeunt: at a good clip. .

 

There is also the rather large elephant in the sky surrounding the long standing safety issue of CASA FOI dictated procedures for EFATO/V1 cuts in the actual aircraft...think Darwin Brasilia...think Essendon DFO accident etc..etc.

Next on the O&O list another possibly partly CASA induced fatal GA accident which has just been updated with an 2nd anniversary interim statement: see - https://www.atsb.gov.au/publications/inv...-2017-013/

Updated: 25 January 2019

The investigation into the collision with water involving a Grumman American Aviation Corp G-73, VH-CQA, 10 km WSW of Perth Airport, Western Australia on 26 January 2017 is continuing.

The final report has completed the drafting phase and is now undergoing an internal review.

Final ATSB investigation reports undergo a rigorous internal review process to ensure the report findings adequately and accurately reflect the analysis of available evidence. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

Following the completion of the internal review, the report will be sent to directly involved parties for comment before the report is finalised and published.

Currently, the anticipated completion and publication date of the final report is during the first quarter of 2019.

Should any safety issues be identified during any phase of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

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Final report: Internal review
Final ATSB investigation reports undergo a rigorous internal review process to ensure the report adequately and accurately reflects the evidence collected, analysis, and agreed findings of the Safety Factor Review. Final investigation reports also undergo other technical and administrative reviews to ensure the reports meet national and international standards for transport safety investigations.

If a review identifies any issues with a report, such as information that needs to be expanded or findings that need to be modified, investigators will look to collect new evidence or conduct additional examination and analysis of existing evidence. P2 - code for PC'ing the Final Report

Note: I have been reliably informed that there is a lot more than meets the eye and to play out with this accident investigation...     

 Finally from the Hooded Canary's top draw of high profile O&O'd accidents an update to the Birdstrike/broken tail VARA ATR accident, which saw the aircraft flying with a badly bent horizontal stabilizer for 5 days and 13 sectors after the accident flight   : https://www.atsb.gov.au/publications/inv...-2014-032/ 

Again the web page for this AAI was listed as being recently updated - Last update 20 November 2018 - . 

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 Organizationas 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.

However the progress listing for the investigation seems to be eternally stuck in the 'Final report: External review' phase? Therefore, given the 4th anniversary for this accident is less than a month away, it is highly likely this AAI will go well into it's 4th year of being dormant but active at the same time - UDB!   



MTF...P2  

Ps P2 comment - When you consider that all three of the above investigations have passed (or shortly will pass) their 2 year anniversaries, kind of makes the bollocks, blame the pilot at all costs, YMEN DFO complex investigation final report an aberration and very, very suspect...