[Peetwo]

Proper AAI vs 'Lies, damned lies and Dr Godlike' -   

While we wait for the running of the nearly 3 year Hooded Canary Rossair cover-up report, note the following off the Accidents OS thread...  

Jan 30, 2019, in Canada.

Beechcraft B200 accident. Well worth a read through.  -  HERE

Please note, today's date April 30, 2020. Not too shabby a turn around time for a very good, professional, valuable report. Nicely done Canada.

UP thread with Centaurus summary - 

Canadian accident King Air-200 loses both AH's in IMC and crashes

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https://www.tsb.gc.ca/eng/rapports-r.../a19w0015.html


This accident report on a King Air 200 is from Transport Safety Board Canada.

The copilots AH was u/s after engine start. Normally the MEL would preclude flight. The captain assumed the copilots AH could eventually come good with time and elected to continue with the flight. The first officer was unhappy about the captain's decision. After takeoff it was obvious the F/O's AH was inoperative and he again told the captain who reassured the F/O the AH would come good eventually. In fact the AH was unserviceable.

During en route cruise in IMC the captains AH also failed. The autopilot disconnected. The captain attempted to fly on partial panel in IMC.but soon became disorientated

The aircraft went into a steep spiral dive and broke clear of IMC at 2000 ft agl. The captain was unable to recover in time and the aircraft crashed at 400 knots.

Note the following from the Canuck TSB report: 

This report concludes the Transportation Safety Board of Canada’s investigation into this occurrence. The Board authorized the release of this report on 18 March 2020. It was officially released on 27 April 2020.

That is 1 year, 1 month and 13 days to complete a reasonably complex investigation - 

Now compare that to this mostly desktop, simple 3 year, 7 month, 16 day investigation into the cause of drum stock fuel contaminants near Cloncurry aerodrome in September 2016...  : https://www.atsb.gov.au/publications/inv...-2016-144/   

This is an extract from the bollocks media presser that accompanied that report...

 

...Mr Macleod noted that the investigation established that no contaminants were found in any aircraft exposed to the fuel.


“Filtration during the refuelling process appears to be effective in preventing these contaminants from reaching the aircraft and there was no evidence that the sealant dissolved in the fuel.”

The report notes it is possible that the sealant may break down into small enough pieces to pass through a fuel transfer pump’s micronic pre-filter and reach the aircraft’s fuel tank, and from there pass through the aircraft’s fuel filtration system and enter the engine.

“However, if that was to occur, the particles would be in minor quantities and too small to affect engine operation,” Mr Macleod said.

“As long as fuel is filtered as required under the regulations, and in accordance with best practice, harmful contaminants should not be able to reach the aircraft.”  - FDS!   

On another matter, I note that the almost inevitable smokescreen to the Rossair FR was wafted out yesterday by the ATCB's real boss Dr God-like, when he released his much anticipated latest round of pointless, bollocks aviation occurrence stats for the last decade...  : 

ATSB releases Aviation Occurrence Statistics report



The Australian Transport Safety Bureau has released its latest Aviation Occurrence Statistics report, covering the 10-year period from 2010 to 2019.

“Each year, thousands of safety occurrences involving Australian aircraft and foreign‑registered aircraft operating in Australia are reported to the ATSB,” said Dr Stuart Godley, ATSB Director Transport Safety.

“This report is part of a series that aims to provide information and statistical data to the aviation industry, manufacturers and policy makers, as well as to the travelling and general public, about these aviation safety occurrences. In particular, the data can be used to determine what can be learned to improve transport safety in the aviation sector.”

This latest Aviation Occurrence Statistics report notes that there have been no fatalities in scheduled commercial air transport in Australia since 2005, while that over the 10-year 2010-2019 period, the number of general aviation fatalities and fatal accidents decreased, and the number of fatalities and fatal accidents within the recreation aviation sector remained relatively constant.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety.

The study uses information over the 10-year period from 2010–2019 to provide an insight into current and possible future trends in aviation safety, Dr Godley explained.

“For example, since 2016, remotely piloted aircraft have surpassed helicopters to become the second most common aircraft type involved in an accident. Further, the number of manned aircraft experiencing near encounters with an RPA also increased significantly over the study period.”

Dr Godley also noted that for the first time, statistics in this report have been organised around the type of aircraft activity being conducted, rather than the operational regulation.

“An activity type reflects the activity the aircraft was engaged in, while an operation type reflects the legal regulation that the aircraft was flown under,” he said.

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

The report incorporates interactive web versions of all tables and graphs to allow the user to display aviation occurrence data in the format of their choice.



Read the report AR-2020-014: Aviation Occurrence Statistics 2010 to 2019
Related: Aviation statistics

Hmm...doesn't this line smack of sheer hypocrisy?? 

“For instance, all ferry flights are now recorded under the same activity irrespective of whether the ferry flight was a positioning flight for a commercial air transport passenger flight or an aerial work flight.”

From Hansard for 04/09/19 :

Senator PATRICK: Okay, we don't have to take that on notice now. We know the answer is zero, and we got to the end of the entire investigation without talking to any Angel Flight pilots about pressure. I want to go back to the statistics. I'm reading this as saying that, if you include the prepositioning flights, Angel Flight comes up at 1.5 accidents per 10,000 flights, and you've got the other flights coming up at much higher numbers.

Dr Godley : Sorry, could you say that again?

Senator PATRICK: Looking at page 69, if you include the prepositioning flights and postpositioning flights—

Dr Godley : So you're just talking about the subset of accidents now?

Senator PATRICK: Yes.

Dr Godley : And that was Senator Brockman's point, yes.

Senator PATRICK: Was it a discretionary choice, or some choice you made, in respect of not including prepositioning flights, or is there some standard by which that is the requirement for these investigations?

Dr Godley : If you look at the current definition of a community service flight that CASA put out—

Senator PATRICK: No—

Dr Godley : it's about passengers.

Senator PATRICK: That definition actually came out two years after this accident occurred.

Dr Godley : But it is consistent with that—

Senator PATRICK: It's semantics. The reality is that the flights start—the pressure starts—from the moment they first get out onto the tarmac at their original location. They know they need to get to wherever they need to get to to pick up the passenger. Probably the last sector has less pressure on it. It just seems totally against all reasonableness to cut out those flights. I am just wondering what—

Dr Godley : As we said, we did—

Senator PATRICK: In terms of international standards, are there any international standards that suggest that the way you are doing it is the way that it should be done?

Dr Godley : There is no international standard, but, as I said before, we made our conclusions—

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From the report: https://www.atsb.gov.au/publications/2020/ar-2020-014/

Background to change


In 2013, recommendations by the Tenth Session of the Statistics Division of the International Civil Aviation Organization (ICAO) were adopted by the ICAO Council and a new edition of the Reference Manual on the ICAO Statistics Program was published. Included within the manual was a new ICAO Classification of Civil Aviation Activities.

The Australian Bureau of Infrastructure, Transport and Regional Economics (BITRE) adopted ICAO’s new classification in 2014 and began collecting statistics in their General Aviation Activity Survey (which the ATSB uses to calculate rate data presented in this report) to reflect this change.

In 2019 the ATSB adopted the new activity classification to better align with BITRE and ICAO. The ATSB conducted a multi‑year project to reclassify over 320,000 occurrences and events within the ATSB occurrence database to include the new activity classification. As a result, the ATSB’s occurrence data now closely aligns with BITRE’s classification and therefore reduces most of the uncertainty associated with combining the databases. These changes mean the ATSB will be able to present more accurate, higher resolution rate data (the best measure for comparison between activities) for more activities than previously.

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Senator PATRICK: So you made a choice?

Dr Godley : based on all incidents. When you look at prepositioning flights as well as passenger flights, it's still higher for all those together. But there is a difference between prepositioning flights and passenger flights, so the risk is not the same; the risk is slightly higher. It is higher when there are passengers on board.

Hmm...Dr G brings a whole new perspective to the line...'lies, damned lies and statistics' - 

MTF...P2   

ps 11:30 EST - still waiting "K" 

Renmark C441 Rossair accident report finally released - 

Only took 1067 days but finally here it is...  

Via the ATCB:

Accident highlights risks inherent in simulated engine failures after take-off



A twin-engine Cessna 441 Conquest collided with the ground shortly after take-off following a simulated engine failure at about 400 feet when the aircraft did not achieve the expected single-engine climb performance or target airspeed.

An ATSB investigation into the 30 May 2017 accident, near Renmark, South Australia, which resulted in the deaths of the three pilots on board, found the lack of expected performance was likely due to the method of simulating the engine failure, pilot control inputs or a combination of both. The investigation also established that normal power on both engines was not restored when the expected single engine performance and target airspeed were not attained.

“That was probably because the degraded aircraft performance, or the associated risk, were not recognised by the pilots occupying the control seats,” said ATSB Executive Director Transport Safety Nat Nagy.

“Consequently, about 40 seconds after commencing the simulated engine failure exercise, the aircraft experienced an asymmetric loss of control, and impacted the ground about four kilometres west of Renmark Airport.”

If one engine inoperative training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

The aircraft, operated by Adelaide-based Rossair, was conducting a check flight on the Cessna 441 for Rossair’s chief pilot by a Civil Aviation Safety Authority (CASA) flight operations inspector (FOI). In turn, the chief pilot was conducting a check of an experienced Cessna 441 pilot who was rejoining Rossair after a period away from the company. The inductee pilot was the pilot flying and was seated in the aircraft’s front left control seat, the chief pilot was seated in the front right seat, and the CASA FOI was observing and assessing the flight from the first passenger seat directly behind the left-hand pilot seat.

They were operating a return flight from Adelaide Airport via Renmark, with a number of flight exercises planned as part of the inductee’s check flight, including the simulated engine failure after take-off on departure from Renmark.

“Conducting the engine failure exercise after the actual take-off meant that there was insufficient height to recover from the loss of control before the aircraft impacted the ground,” said Mr Nagy.

Noting that there is no Cessna Conquest simulator in Australia, the investigation highlights that one engine inoperative training should follow the manufacturer’s guidance and, where it is possible, be conducted in an aircraft simulator.

Mr Nagy said if one engine inoperative (OEI) training sequences are conducted close to the ground, then effective risk controls need to be in place to prevent a loss of control, as recovery at low height will probably not be possible.

“These risk controls can include defined OEI performance criteria that, if not met, require immediate restoration of normal power; use of the appropriate handling techniques to correctly simulate the engine failure and ensuring that aircraft drag is minimised/OEI performance is maximised; and ensuring that the involved pilots have the appropriate recency and skill to conduct the exercise and that any detrimental external factors, such as high workload or pressure, are minimised.”

The investigation also identified a number of safety factors, although they did not necessarily contribute to the accident flight. These included:

• The operator’s training and checking manual procedure for simulating an engine failure in a turboprop aircraft was inappropriate and increased the risk of asymmetric control loss;
  
  
• The CASA flying operations inspector was not in a control seat and was unable to share the headset system used by the inductee and chief pilot;
  
  
• The inductee and chief pilot, while meeting recency requirements, had limited recent experience in the Cessna 441;
  
  
• The chief pilot and other key operational managers within Rossair were experiencing high levels of workload and pressure; and
  
  
• CASA’s method of oversighting Rossair increased the risk that organisational issues would not be identified and addressed.
  

Mr Nagy also noted a lack of recorded data from the aircraft reduced the amount and type of evidence available to investigators about handling aspects and cockpit communications, as the aircraft was not fitted with a cockpit voice recorder or flight data recorder, and nor was it required to be.

“This limited the extent to which potential factors contributing to the accident could be analysed.”

Read the investigation report AO-2017-057: Loss of control and collision with terrain involving Cessna 441, VH-XMJ, near Renmark Airport, South Australia on 30 May 2017