[Peetwo]

Popinjay continues to take the PISS on ICAO Annex 13 compliance??

Via ICAO:

Per Annex 13, the State conducting the investigation of an accident or incident is expected to produce a Preliminary Report within 30 days of the accident. This Preliminary Report may be public or confidential at the discretion of the State in charge.

Courtesy Popinjay HQ, prelim report AO-2023-051 was released 89 days after the fatal accident occurred...

Via, PJ's bureaucratic top-cover, load of absolute self-serving (un-interactive) media release bollocks...

Preliminary report details initial evidence gathered in Hawks Nest R66 helicopter accident


The accident helicopter’s flight path

The Australian Transport Safety Bureau has released a preliminary report from its ongoing investigation into a Robinson R66 helicopter’s in-flight break-up and collision with water near Hawks Nest, NSW on 26 October 2023.

“Today’s preliminary report provides factual information from the initial evidence gathering phase of the investigation, including detailing this tragic accident’s sequence of events,” ATSB Chief Commissioner Angus Mitchell said.

About half an hour before the accident, the helicopter departed Cessnock for Wallis Island, on the NSW north coast, and initially tracked east towards Newcastle, flying close to the cloud base, which was between 500 ft and 1,000 ft above ground level.

Approaching the coast, the pilot received clearance from Williamtown air traffic control to transit Williamtown airspace northbound at 500 ft above mean sea level (AMSL).

As the helicopter reached Anna Bay, Williamtown air traffic control then provided the pilot with a further clearance to follow the coastal VFR route below 2,000 ft AMSL.

“The helicopter’s onboard video camera showed at this time that the helicopter’s autopilot was engaged, with heading hold and altitude mode selected,” ATSB Chief Commissioner Angus Mitchell said.

As it tracked towards Hawks Nest, the helicopter passed over the south shoreline of Yacaaba Headland, to the west of Mount Yacaaba, at about 900 ft AMSL.

Analysis of the onboard video footage showed that the helicopter then experienced a series of initially minor changes in roll, pitch and yaw, and the pilot began to make cyclic inputs, overriding the autopilot.

“As the helicopter passed north of Yacaaba Headland and over Providence Bay it rolled left slightly, then right and left to bank angles of about 10 to 15 degrees. During this time, the nose remained pitched up at about 6 degrees and the helicopter climbed to about 1,100 ft AMSL,” Mr Mitchell said.

“Subsequently the helicopter’s nose pitched down and it rolled to the right, becoming completely inverted, and continuing to roll right to about 270 degrees.”

The ATSB’s subsequent wreckage examination determined that, during the accident sequence, the main rotor likely impacted the cabin and struck and separated the tail boom aft of the engine fairing.

The helicopter impacted the waters of Providence Bay, near Hawks Nest, and the pilot was fatally injured.

Mr Mitchell noted that the helicopter’s onboard camera is proving invaluable to the investigation, as it not only recorded the in-cabin visual and audio environment, but also captured GPS position, acceleration, and rotational speed.

“We were very fortunate that a roof panel to which the camera was mounted washed up on the beach near the accident site and was located by a member of the public who provided it to the NSW Police,” Mr Mitchell said.

“The video files and other recorded data were subsequently extracted from the camera memory module at the ATSB’s technical facilities in Canberra.”

Williamtown air traffic control radar and radio communications between the helicopter have also been retained by the ATSB for analysis.

“As we continue the investigation we will further analyse the onboard video, continue to examine recovered components, and look into flight planning and helicopter performance, amongst other aspects,” Mr Mitchell said.

“Investigators are also closely examining the meteorological conditions at the time of the accident, particularly in the immediate vicinity of Mount Yacaaba.”

The ATSB’s final investigation report will detail findings, any identified safety issues, and safety actions taken to address those.

“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.”

Read the preliminary report: Loss of control and in-flight break-up involving Robinson R66, VH-KFT, near Hawks Nest, New South Wales, on 26 October 2023

Publication Date: 23/01/2024

 
“However, if we identify a critical safety issue during the course of the investigation that requires timely safety actions, we will immediately notify relevant parties.” - Hmm...the funny thing is although this bollocks statement is continuously regurgitated in all ATSB preliminary reports and associated bollocks MRs, there is in fact no longer any 'critical safety issue' definition published on the ATSB website - see previous post...

However a CSI is annually defined (for at least the last 5 years) in the ATSB Annual Report - WTD??

Via ATSB Transparency Portal:

Formal safety issues and actions

ATSB investigations primarily improve transport safety by identifying and addressing safety issues. Safety issues are events or conditions that increase safety risk and:

• can reasonably be regarded as having the potential to adversely affect the safety of future operations
  
• are characteristics of an organisation or a system, rather than of a specific individual, or operational environment at a specific point in time.
  

Safety issues will usually refer to an organisation's risk controls, or to a variety of internal and external organisational influences that impact the effectiveness of its risk controls. They are factors for which an organisation has some level of control and responsibility and, if not addressed, will increase the risk of future accidents.

The ATSB prefers to encourage stakeholders to take proactive safety action to address safety issues identified in its reports. Nevertheless, the ATSB may use its powers under the TSI Act to make a formal safety recommendation either during or at the end of an investigation – depending on the level of risk associated with a safety issue and the extent of corrective action already taken.

When safety recommendations are issued, they clearly describe the safety issue of concern, but they do not provide instructions or opinions on a preferred corrective action. Like equivalent overseas organisations, the ATSB has no power to enforce the implementation of its recommendations. It is a matter for the organisation to which an ATSB recommendation is directed to assess the costs and benefits of any means of addressing a safety issue, and act appropriately.

When the ATSB issues a safety recommendation to a person, organisation or agency, they must provide a written response within 90 days. That response must indicate whether they accept the recommendation, any reasons for not accepting part or all of the recommendation, and details of any proposed safety action to give effect to the recommendation.

The ATSB can also issue a safety advisory notice (SAN) suggesting that an organisation, or an industry sector, consider a safety issue and take appropriate action. There is no requirement for a formal response to a SAN.

Safety issues are broadly classified in terms of their level of risk:

• Critical safety issue – associated with an intolerable level of risk and generally leading to the immediate issue of a safety recommendation unless corrective safety action has already been taken.
  
• Other safety issue – associated with a risk level regarded as unacceptable unless it is kept as low as reasonably practicable. Where there is a reasonable expectation that safety action could be taken in response to reduce risk, the ATSB will issue a safety recommendation to the appropriate agency when proactive safety action is not forthcoming.
  

All ATSB safety issues and associated safety actions, along with the most recent status, are published on the ATSB website for all investigation reports released since July 2010.

       
MTF...P2