AO -2014 – 032. Adding insult to inujry.
When Dolan invented the ‘Beyond Reason’ method of accident investigation, I think most understood that it was a load of old cobblers – designed to throw the Senate investigation into the Pel-Air shambles off the scent. I doubt there was even a professional airman, let alone a qualified accident investigator who believed a word of it. We all expected that would be last time this chimera raised its ugly, misbegotten head. Wrong: not only has Hood adopted it, but has actually set about installing it as the new ‘norm’. “Bullshit” howls the mob. “Unbelievable is it – read this” is the reply. Shocked silence follows the reading.
Which is about where I am – slightly shocked and bordering on furious having read through this ‘thing’ called a ‘report’. For a start I wonder how could this event could ever have taken place. Seriously; it should never have occurred. But it did and we need to examine why it did, there are some serious, deadly serious safety implications being ignored; written out of the script by ATSB. AP has a team working on this puerile ATSB disgrace as we speak; and, that analysis of this report (soup to nuts) will be made as public as is within our reach. For an entrée, let’s take an overview.
There are many ATR aircraft floating about this planet; it is a success story; a tough, dependable, work horse which earns it’s keep and generates profits for the operators. Every aircraft type, since the Wright brothers kicked off has ‘niggles’ and ‘stuff’ which give the aircraft its ‘character’. The ATR is a turbo prop and operates best where jet aircraft are impractical, this often means ‘tough’ environments; all the bells and whistles; storms, ice, wind shear; fog, adverse winds, short runways, mountains and their tricky winds, islands and their unique conditions etc. Routine stuff – part of a flying life. The ATR not only survive in this, but thrive in it. Not too many instances of elevator channel disconnect mentioned – despite hard work in tough ports is there. Yet here we have a serviceable aircraft busted in relatively benign conditions, in clear sky, in daylight en-route to a major aerodrome, because – Why?
The next element is why the aircraft was not only returned to service after the event; but allowed to continue operating. Which begs other questions related to inspection pre flight.
AP will begin at the beginning – Human Factors. Company ethos and the subliminal pressures placed on flight crew. For example – OTP and slot times. OTP (On Time Performance) is a management toy – a thing of advertisement and bonus; which has SDA to do with flight crew. Then we have Flight and Duty times which, once again, have SDA to do with crew. Yet these elements impact on the crew. Where this leads is to the ‘push to rush’. When you factor in the ‘macho’ thing – there is a good case supporting high speed descent. Red line at 250 KIAS – descent at 250 KIAS - . Not prudent. Item next – computers; despite the rumours, do not have a brain – they can’t think; let alone see and read the sky. The Auto pilot simply does as asked – without being obliged to anticipate anything. Add to this a crew which completely disregarded not only the ‘clues’ but SOP and common sense and you end up with a busted aircraft; and terrifyingly – a series of flights, each of which could have ended in disaster. ATR reliability and inherent ‘toughness’ demonstrated - yet again. Not only did it get the passengers safe home – but went on to do again and again without failing: i.e. the tail remained attached to the airframe.
It is reasonable to question one other element before you begin to take this episode apart – operating policy. For some reason the nominal height of 400 feet has become fixed in the mind of operators – at 400’ the Auto Pilot must takes over flying duties. Two things very wrong with this. (1) 400’ is not always the Obstacle Clearance Height (OCH) for the weight/ temperature/ flight path; (2) the AP will simply correct for an out of whack control surface. IMO a pilot worth the name would; if actually flying the aircraft, pick up ‘something’ wrong with the arse end and report it – next landing. (Gods willing - weather permitting). Selah.
This much delayed, obfuscated report into the ATR is, IMO an insidious danger to navigation. Hood should resign and the report redrafted to correct the glaring obscenities contained. Will the real investigators please speak up – before it’s too late and the acronym ATSB becomes an international disgrace.
Toot – toot.
When Dolan invented the ‘Beyond Reason’ method of accident investigation, I think most understood that it was a load of old cobblers – designed to throw the Senate investigation into the Pel-Air shambles off the scent. I doubt there was even a professional airman, let alone a qualified accident investigator who believed a word of it. We all expected that would be last time this chimera raised its ugly, misbegotten head. Wrong: not only has Hood adopted it, but has actually set about installing it as the new ‘norm’. “Bullshit” howls the mob. “Unbelievable is it – read this” is the reply. Shocked silence follows the reading.
Which is about where I am – slightly shocked and bordering on furious having read through this ‘thing’ called a ‘report’. For a start I wonder how could this event could ever have taken place. Seriously; it should never have occurred. But it did and we need to examine why it did, there are some serious, deadly serious safety implications being ignored; written out of the script by ATSB. AP has a team working on this puerile ATSB disgrace as we speak; and, that analysis of this report (soup to nuts) will be made as public as is within our reach. For an entrée, let’s take an overview.
There are many ATR aircraft floating about this planet; it is a success story; a tough, dependable, work horse which earns it’s keep and generates profits for the operators. Every aircraft type, since the Wright brothers kicked off has ‘niggles’ and ‘stuff’ which give the aircraft its ‘character’. The ATR is a turbo prop and operates best where jet aircraft are impractical, this often means ‘tough’ environments; all the bells and whistles; storms, ice, wind shear; fog, adverse winds, short runways, mountains and their tricky winds, islands and their unique conditions etc. Routine stuff – part of a flying life. The ATR not only survive in this, but thrive in it. Not too many instances of elevator channel disconnect mentioned – despite hard work in tough ports is there. Yet here we have a serviceable aircraft busted in relatively benign conditions, in clear sky, in daylight en-route to a major aerodrome, because – Why?
The next element is why the aircraft was not only returned to service after the event; but allowed to continue operating. Which begs other questions related to inspection pre flight.
AP will begin at the beginning – Human Factors. Company ethos and the subliminal pressures placed on flight crew. For example – OTP and slot times. OTP (On Time Performance) is a management toy – a thing of advertisement and bonus; which has SDA to do with flight crew. Then we have Flight and Duty times which, once again, have SDA to do with crew. Yet these elements impact on the crew. Where this leads is to the ‘push to rush’. When you factor in the ‘macho’ thing – there is a good case supporting high speed descent. Red line at 250 KIAS – descent at 250 KIAS - . Not prudent. Item next – computers; despite the rumours, do not have a brain – they can’t think; let alone see and read the sky. The Auto pilot simply does as asked – without being obliged to anticipate anything. Add to this a crew which completely disregarded not only the ‘clues’ but SOP and common sense and you end up with a busted aircraft; and terrifyingly – a series of flights, each of which could have ended in disaster. ATR reliability and inherent ‘toughness’ demonstrated - yet again. Not only did it get the passengers safe home – but went on to do again and again without failing: i.e. the tail remained attached to the airframe.
It is reasonable to question one other element before you begin to take this episode apart – operating policy. For some reason the nominal height of 400 feet has become fixed in the mind of operators – at 400’ the Auto Pilot must takes over flying duties. Two things very wrong with this. (1) 400’ is not always the Obstacle Clearance Height (OCH) for the weight/ temperature/ flight path; (2) the AP will simply correct for an out of whack control surface. IMO a pilot worth the name would; if actually flying the aircraft, pick up ‘something’ wrong with the arse end and report it – next landing. (Gods willing - weather permitting). Selah.
This much delayed, obfuscated report into the ATR is, IMO an insidious danger to navigation. Hood should resign and the report redrafted to correct the glaring obscenities contained. Will the real investigators please speak up – before it’s too late and the acronym ATSB becomes an international disgrace.
Toot – toot.