[Peetwo]

ATSB still taking the Mickey Bliss on ICAO Annex 13...

Unfortunately they ran out of time to have Hoody & crew appear at Estimates last night. However I have it on good authority that an additional public hearing date will be announced by the committee, hopefully sooner rather than later...

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:

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: 

"..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..."


(P2 - Eight days now and still no sign of any interim report on the VARA ATR broken elevator accident... )

Not wanting to flog an obvious dead horse, as far as the Hood led ATSB are concerned; but the following are two ICAO references in regards to 'interim reports' and/or statements:

First to an ICAO newsroom 'fact sheet' on AI & reports:

Accident Investigation

Article 26 of the Convention on International Civil Aviation (Chicago Convention) states that, in the event of an accident to an aircraft of a Contracting State occurring in another Contracting State, and involving either death, serious injury, or serious technical defect in the aircraft or air navigation facilities, the State in which the accident occurs will institute an inquiry into the circumstances of the accident.

Annex 13 (Aircraft Accident and Incident Investigation) to the Convention provides further international requirements for the investigation of aircraft accidents and incidents. It spells out which States may participate in an investigation, such as the States of Occurrence, Registry, Operator, Design and Manufacture. It also defines the rights and responsibilities of such States.

The State of Occurrence may delegate all or part of the investigation to another State or a regional accident and incident investigation organization, and may call on the best technical expertise available from any source to assist with the investigation. States of Registry, Operator, Design and Manufacture who participate in an investigation are entitled to appoint an accredited representative (with or without associated advisers) to take part in the investigation.

A State which has a special interest in an accident, by virtue of fatalities or serious injuries to its citizens for instance, is entitled to appoint an expert entitled to: visit the scene of the accident; have access to the relevant factual information which is approved for public release by the State conducting the investigation, and information on the progress of the investigation; receive a copy of the accident investigation Final Report. ICAO officials only participate in accident investigations upon special request from the State responsible for conducting the investigation.

How are Annex 13 accident investigations reported?

States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

The State conducting the investigation of an accident or incident shall also make the Final Report publicly available as soon as possible and, if possible, within twelve months. If the report cannot be made publicly available within twelve months, the State conducting the investigation shall make an interim statement publicly available on each anniversary of the occurrence – detailing the progress of the investigation and any safety issues raised. For accidents or incidents involving an aircraft of a maximum mass over 5 700 kg, States in charge of an Annex 13 investigation must make the Final Report available to ICAO.

For more information please contact:
communications@icao.int

The statement in bold reflects the general practice of most responsible ICAO signatory countries with an independent aviation accident/incident investigation capacity, as per and in compliance with ICAO Annex 13 Para 6.6:

 ..The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised.

An example of compliance by a signatory state is with the high profile MH370 investigation, which on each anniversary the Malaysian AAIB (so far) have adhered to by issuing either an 'interim factual report' (2015) and last year an interim statement.

However in the Australian case there are numerous examples where the anniversary Annex 13 SARP has been completely ignored without even a press or social media statement.

Update: 07:30 Report tonight...

Caught by Cap'n Wannabe today...

ATSB starring on 7:30 Report -

Excellent catch Wannabe...  

Also apparently going to be on the 07:30 Report tonight:
Excellent catch Wannabe...  

Also apparently going to be on the 07:30 Report tonight:

Air safety watchdog 'clearly failing': Two-thirds of investigations not completed in required time. #abc730 @L_Day http://ab.co/2mZEEUe pic.twitter.com/zWBikD3klJ

Air safety watchdog 'clearly failing': Two-thirds of investigations not completed in required time
7.30
By Lauren Day
Updated about an hour agoTue 7 Mar 2017, 4:55pm

The body that investigates air safety incidents is struggling with a massive backlog and is only completing one in three investigations inside the targeted 12-month timeframe.

Key points:

• ATSB aims to complete 90 per cent of investigations within 12 months
  
• It is only completing 29 per cent of investigations in that time
  
• Neil Hansford believes the ATSB has been hampered by the search for MH370
  

The Australian Transport Safety Bureau (ATSB) has been in the spotlight since it was revealed the pilot involved in last month's plane crash near Essendon Airport was being investigated over a near collision at Mount Hotham in 2015.

The delay in completing investigations is leaving grieving families in limbo and poses a real risk to aviation safety.

"Until a case is resolved, there can be no remedial action taken by the relevant authorities, CASA (Civil Aviation Safety Authority) or the Department of Transport or even private airport operators," aviation safety expert Neil Hansford told 7.30.

"So it's critical that the ATSB hit their key performance indicators as mandated by the Government.

"If they can't do that we have to look at the whole role of the ATSB."

Do you know more about this story? Email 7.30syd@your.abc.net.au
Has the MH370 search gotten in the way?

Video: Aerial footage shows plane crash site at a shopping centre near Essendon Airport (Courtesy Channel 9) (ABC News)

The ATSB aims to complete 90 per cent of all complex investigations within 12 months. But in 2016 it only managed to complete 29 per cent within the stipulated time, with several investigations still remaining open after years.

"When you are only achieving under 30 per cent of closure in line with your key performance indicators and they've got you at 90 per cent, clearly you're failing," Mr Hansford said.

"If you were in private enterprise, you'd be unemployed, you'd have a new boss and you'd be taken apart because they should have put up their hands and said 'this is going to have an effect on the Australian aviation market and we're not going to be able to deliver our requirements as laid out by the Government'."


Photo: Pilot Max Quartermain was being investigated by the ATSB when his plane crashed near Essendon Airport. (Supplied: Corporate and Leisure Aviation)

Mr Hansford believes the ATSB's failure to meet its investigation targets is linked to its role in the search for downed Malaysian Airlines plane MH370.

"It's had a major effect, because the number of resources, of people. You just take on the investigation regarding Essendon; there are four investigators on the scene almost immediately, now that's for one small aircraft.

"Now, have a look at the effect of an aircraft where we didn't know where it was, as the head of the Air Force said, 'I'm not looking at a needle in a haystack, I haven't even found the haystack.'

"So imagine the labour and the specialist people who were assigned to that.
"They weren't doing the jobs they were mandated and paid for, which is the protection of the Australian aviation industry."

'It's very frustrating, we can't put it behind us'


Photo: John Davis was killed in a helicopter crash in November 2015. His wife is still waiting for answers. (Supplied)

Felicity Davis lost her husband in a helicopter crash in November 2015.

John Davis was flying with friends, Richard and Carolyn Green, shooting aerials for a documentary on coal mining when the chopper crashed.

They were supposed to be gone for only a few hours, but when they failed to arrive at their destination a search was launched.

After an agonising wait, Ms Davis called the police for an update.

"They rang me back five minutes later and said, 'We found the helicopter and unfortunately there were no survivors.' So, that was it.

"I just couldn't believe it, I just couldn't believe it."

Now, 16 months later, Ms Davis is still waiting for the ATSB to tell her what happened in the crash.

All she can do is speculate.

"It's very frustrating because we can't put it behind us, get it over and done with," she said.

One of those unfinished reports related to pilot Max Quartermain, who crashed into a shopping centre at Essendon Airport last month.

After his "near collision" in 2015, a proficiency test found him capable to fly.
That Mt Hotham near miss was nearly 18 months ago, but the completion of the investigation has been delayed three times due to competing priorities and workload of the investigator in charge.

"This is one where the report has not being published and the excuse has been we didn't have the resources," Mr Hansford said.

"So the question has to be, if that had been resolved, would Mr Quartermain still be flying and what other aspects regarding the aircraft types and what happened at Mount Hotham?"


'Safety remains paramount'

Video: Questions raised about safety of suburban airports after plane crash kills five (7.30)

Ben Morgan is the head of the Aircraft Owners and Pilots Association, which also has major concerns about how the ATSB operates.

"One of the most upsetting things that happens after an air accident is the media starts reporting on a wide gamut of historical reports that involve pilots within our industry," he said.

"It does subject the pilot to an unfair assessment by the community.

"We need an ATSB who is far more responsible in getting these reports completed quickly.

"We cannot have scenarios where we're waiting five and seven years to wrap up an investigation.

"The aviation community needs the reports rapidly, the community needs the reports rapidly, so that we can obviously ensure that safety remains paramount."

Mr Morgan points to a lack of resources at the ATSB, saying the organisation has had its staff cut by 25 per cent since 2009.

"The aviation industry for some time has been raising concerns to both the Department of Transport and Minister for Transport, Darren Chester, in that air accident investigations are simply taking too long," he said.

"We have a scenario in which the ATSB would appear now to be vastly understaffed and underfunded and this has been a direct result of the fact that we no longer have a Minister in Government who has a strong interest in aviation."

Both the Transport Minister and the ATSB declined 7.30's request for an interview.
But in a statement, the ATSB acknowledged it faced resourcing challenges.

Its annual report said that would be addressed by being more selective in how it allocates its resources

In contemplating the unacceptable time delays with a large percentage of ATSB investigations it is worth referring to Chapter 3.69 of the Senate Pel-Air cover-up report:

Time taken to produce the ATSB report

3.69      The ATSB's statement of intent, available online, includes an undertaking to conduct investigations in a timely manner and 'aim to issue final reports on investigations within one year from commencement.'[45]

3.70      The aspirational goal certainly did not translate into reality in this instance. Instead, the ATSB's report on the ditching of VH-NGA took nearly three years to complete. The committee is not aware of any suggestions that this was a reasonable, or indeed helpful, timeframe within which to produce a report meant to allow the industry to learn lessons from this accident.

3.71      On the contrary, witnesses called the three year timeframe unreasonable and described it as being 'outside the performance expectations set by the ATSB and other international agencies.'[46]

3.72      ATSB Chief Commissioner Dolan admitted that the time taken to produce the report was unsatisfactory:

I should say up front that there are two areas where we think we could have done better with this investigation and report. The first and obvious one is that it took us far too long by anyone's standards, including our own, to get to a completion of the investigation. There are reasons for that, which I would be happy to discuss, but they do not excuse the three-year time frame for the report.[47]

3.73      Mr Dolan's explanation for the time taken to produce the report essentially revolved around resource allocation and prioritisation:

When, nearly 3½ years ago, I joined the newly independent ATSB as chief commissioner, we had over 100 aviation investigations on hand, including four that we classified as level 2—so substantial investigations requiring major and continuing use of our resources. We were averaging about 18 months for the completion of investigations, with some serious outliers in that. We had more work on hand than we knew how to deal with, and we would normally expect in any given year to get one of those level 2 investigations. So we had a lot more work than we were used to. That led to delays in a range of reports and, as new investigations came in, the shifting of resources to different priorities as they arose. It is clear that, in managing that allocation of resources to always-shifting priorities, we did not give enough attention to getting to an expeditious conclusion of this Norfolk Island report. However, that is the context in which that happened.[48]

3.74      The committee understands that strategic guidance from the minister leads the ATSB to prioritise investigations into what are referred to as 'fare-paying passenger operations'.[49] These generally exclude the type of flight VH‑NGA was undertaking at the time of the accident, which is categorised as aerial work. The Australian and International Pilots Association (AIPA) suggested that the non-fatal nature of this accident suggests that its investigation was not accorded a high level of priority.[50]

3.75      Like AIPA, the committee understands that the ATSB, like most organisations, has to prioritise its workload.

3.76      When the committee asked whether the ATSB had considered outsourcing any of its work, or insourcing extra capacity to expedite the production of reports, Mr Dolan replied in the negative:

Our resources are largely tied up in maintaining our existing investigative capability, who are permanent staff of the organisation. We have a longstanding view that in almost all circumstances it is better to have, if possible, the range of expertise available to us on a permanent basis and therefore immediately available than to rely on potentially risky external outsourcers.[51]

3.77      The committee confirmed with Mr Dolan that this was the case even when the ATSB budget was underspent and its workload was clearly excessive:

Senator FAWCETT:  I am not talking about normal [ATSB] operations. I am talking about a situation where you have a budget underspend and a clear excess of work.

Was it [outsourcing or insourcing] even considered? That is all I am asking.

Mr Dolan:  In that small underspend, no, we did not consider it.[52]

Committee view

3.78      The committee does not believe that an adequate explanation for the delay has been provided.

3.79      Given that the ATSB could not, or certainly should not, have known that it was only going to identify two relatively minor safety issues at the onset of its      three-year investigation, the delay itself had the potential to risk lives by not alerting the industry to the causes of this accident in a timely fashion.

3.80      The committee considers the fact that it took the ATSB close to three years to produce its investigation report following the November 2009 ditching of VH-NGA unreasonable. The committee also believes that the ATSB made a significant oversight by not considering external assistance despite a budget surplus of $0.3 million in 2009-10.[53]

3.81      Furthermore, the quality and complexity of the final report once it was produced—as will be discussed in later chapters of this report—certainly would not appear to readily justify a three-year timeframe. This being the case, the committee is firmly of the view that the stated aim of producing reports within one year of an incident or accident is attainable and should be met in all but the most extraordinary and justifiable of circumstances. During the course of its investigation, if it becomes apparent to the ATSB that it will not meet its one year timeframe, the ATSB should release an interim report, as required by ICAO, which would include a public timing update to ensure that the aviation industry is kept informed of progress and expected timing.

MTF...P2