[Peetwo]

NTSB (also) searching for IP?

Why does this sound so familiar? - Via the FSD :

Air Disasters in the Making? Accidents Up, Investigation Quality Shoddy – Episode 124

John and Greg have get-real conversation about alarming trends in aviation safety. Accidents are increasing, even among experienced pilots. At the same time, the NTSB has scaled back on investigations and is issuing reports with superficial findings. Are more air disasters in the making?

Pilot shortages are leading to a push for training volume over quality. The college requirement has been removed and there is a push to reduce the flight hours for qualification.

“NTSB findings often talk about the importance of experience and pilot training but they have been silent now that there is a push to lessen the requirements,” Greg notes.

Listen as the Flight Safety Detectives outline many indicators that aviation safety is in jeopardy.

John and Greg will be at EAA AirVenture Oshkosh. See them at the Avemco Insurance booth on Thursday, July 28 at 2 p.m.

Plus, via AvWeb:

Four Dead In Nevada Midair
By Kate O'Connor -Published: July 18, 2022


Image: City of North Las Vegas Fire Department

Four people were killed in a midair collision involving a Piper PA-46 Malibu Mirage and a Cessna 172N Skyhawk at Nevada’s North Las Vegas airport (VGT) on Sunday. Authorities reported that each aircraft had two people onboard. The names of the individuals killed in the crash have not yet been released.

“Preliminary information indicates that the Piper PA-46 was preparing to land when it collided with the Cessna 172,” the FAA said in a statement. “The Piper crashed into in a field east of Runway 30-Right and the Cessna fell into a water retention pond.”

The accident occurred at around 12 p.m. local time and a post-crash fire was reported. According to tower audio recorded by LiveATC.net, the 172, N160RA, was cleared for the option on Runway 30R while the PA-46, N97CX, was cleared to land on Runway 30L. ADS-B tracking data appears to show the PA-46 overshooting the final approach course for 30L. The NTSB is investigating the accident.

https://s30121.pcdn.co/wp-content/upload...-1900Z.mp3
Audio: Jul-17-2022-1900Z – KVGT Tower – LiveATC.net

The crash at VGT is one of eleven fatal general aviation accidents reported in the FAA’s Aviation Safety Information Analysis and Sharing (ASIAS) system between Thursday, July 14, and Sunday, July 18.

This article will be updated as more information becomes available.

Although there are some obvious differences (in the circuit/VFR v IFR etc); it is still a very rare mid-air collision which perhaps can provide a good point of comparison (ie NTSB v ATSB search 4 IP)?? Therefore AP will monitor the progress of the NTSB investigation...

MTF...P2 

[Peetwo]

Popinjay's spin'n'bulldust on YMEN DFO investigation 4+ year delay?? - 

Via Popinjay HQ:  https://www.atsb.gov.au/publications/inv...-2018-010/

Update published 1 August 2022

A third draft of this report will be released to Directly Involved Parties for comment in August 2022. The ATSB undertook a significant review of the available material and sourced additional evidence from organisations in Australia and overseas following the circulation of a draft of the report to Directly Involved Parties in 2019.

Additional work was considered necessary when changes were made to the design of surfaces at Essendon Fields Airport that manage the location and height of buildings in proximity to runway 08/26. These changes were made by the aerodrome operator around the time the draft report was released for consultation. P2 - WTF..   The changes were advised in update 1

The investigation has involved consideration of historically complex subject matter with the application of both Australian and international aerodrome design requirements dating back to the 1970s. The ATSB has applied considerable effort to understanding the application and function of those aerodrome design requirements from the 1970s to the present in the context of changes at Essendon Fields Airport. It has taken the investigation time to overcome the challenges of limited information available from historical periods to provide context to the investigation.

A final report is expected to be released publicly in the last quarter of 2022

 
From update 1 (nearly 2 years ago): 

The Major Development Plan (MDP) for the Bulla Road Precinct retail centre development was approved by the Minister for Transport and Regional Development in 2004. Building of the precinct was completed in 2005. The MDP located the lower boundary of the transitional surface 90 m from the centreline of runway 08/26 (see Figure 1). That distance was founded on two criteria:

• a runway strip width of 180 m (90 m either side of the runway centreline)
  
• the location of the lower boundary of the transitional surface immediately adjacent to the runway being determined by the runway strip dimensions.
  

Using these criteria, the MDP placed the buildings immediately adjacent to and just below the transitional surface associated with runway 08/26. Had they intruded into the transitional surface, an approval would have been required under Part 12 of the Airports Act 1996, and the Civil Aviation Safety Authority (CASA) would have considered the development as being obstacles requiring determination under the relevant safety regulations...

...In November 2015, CASA promulgated CASA instrument 153/15, which was issued to the airport operator. This instrument required the operator to publish the overall strip width for runway 08/26 as 300 m. The basis of this requirement was that there was no record on how the 180 m runway 08/26 strip width had originated, nor were there records as to the previous standard under which that measurement was authorised. The 180 m runway strip width was not authorised under the 2015 version of the standards, which required a 300 m strip width (150 m either side of the runway centreline)...

Why is the ATSB concerned with the actions of the airport operator, the department and CASA (CASA instrument 153/15) post the Minister approved 2004 MDP (which included the approval for the DFO development)? -   

(NB One has to keep in mind that the ranks of the DIPs include the Texan Widows their Families and  lawyers, plus the Victorian coroner - ref pg 7-8: https://www.atsb.gov.au/media/5776657/fo...dacted.pdf ) 


MTF...P2 

[Kharon]

"She swore, in faith 'twas strange, 'twas passing strange;

'Twas pitiful. 'twas wondrous pitiful,"

"The ATSB has applied considerable effort to understanding the application and function of those aerodrome design requirements from the 1970s to the present in the context of changes at Essendon Fields Airport. It has taken the investigation time to overcome the challenges of limited information available from historical periods to provide context to the investigation."

You have to wonder though; don't ya? I would have thought that this matter would end up on the desk of 'serious' investigators, someone like the AG's Integrity/ Anti corruption outfit. They have the expertise to burrow through the twists and turns involved in not only getting the DFO built, the impact on 'side' safety zones and the manipulation runway width etc...The ATSB do not have this level of 'investigative' skills or the horse power to have awkward questions answered and even less in the way of teeth to drag out the answers.

That aside, the ATSB's glib, high speed investigation of all the circumstances attending this accident was less than satisfactory. Pilot error - end of story. What is not clear is the 'how and the why' of the tale. Medical data - tick & flick; past performance - tick and flick; Mayday call-outs - tick and flick. The lack-lustre High Viz Hood steered the investigation through its sorry progress; methinks there are question there that could stand some serious answers. Old mate Popinjay has the wheel now, the current lame excuses are little more than a puff piece to excuse and obfuscate the core matter - and to provide another excuse for delaying tactics. Aye well, the irrepressible urge to see his name in lights has been satisfied - for a short while at least.

"The basis of this requirement was that there was no record on how the 180 m runway 08/26 strip width had originated, nor were there records as to the previous standard under which that measurement was authorised. The 180 m runway strip width was not authorised under the 2015 version of the standards, which required a 300 m strip width (150 m either side of the runway centreline)..."

We know this - what we do not know is who shagged who, who paid for it and what did it cost?

This matter is a question for the AG and the Federal police - the ATSB need to call up the dogs, admit the investigation is beyond their capacity and remit and return to providing sugar frosted top cover for their ministers and masters. Or, better yet, bend their minds to regaining their once stellar international reputation; they can find it in the rubbish bin behind the hanger.

Toot - toot...

[Peetwo]

Popinjay promotes ADS-B rebate program?? -

Via Popinjay central:

The Australian Government has launched a new $30 million Automatic Dependent Surveillance Broadcast (ADS-B) rebate program to support more general and recreational visual flight rules (VFR) aircraft owners to install the technology into their aircraft.

ADS-B transmits GPS-derived position data, aircraft identification and other aircraft performance parameters, which can provide pilots near real-time locational data to enhance their situational awareness of other ADS-B equipped aircraft near-by.

This can aid self-separation from other aircraft, particularly in non-controlled airspace, helping to reduce the risk of collisions.
In Australia, all aircraft operating under instrument flight rules (IFR) are required to be fitted with ADS-B, with its fitment to aircraft operating under VFR voluntary.

To increase the uptake of ADS-B in VFR aircraft, the government is now providing a 50% rebate of the purchase cost of eligible ADS-B devices and, where applicable, the installation, capped to $5,000. Low-cost portable ADS-B devices will also be eligible for the grant.

“Ensuring the safety of our pilots, other aviation workers, passengers and those on the ground is of the utmost importance each and every time a plane takes off, which is why the funding of this technology will make a huge positive impact,”

Infrastructure, Transport, Regional Development and Local Government Minister Catherine King said in announcing the scheme.

The rebate program, which opened on 12 August 2022, directly responds to calls from industry to encourage the uptake of ADS-B technology to realise its many benefits.

“The ‘see and avoid’ principle has known limitations, and the use of ADS-B with a cockpit display or an electronic flight bag application showing traffic information greatly improves a pilot’s situational awareness and enhances the safety of their flight,” Australian Transport Safety Bureau Chief Commissioner Angus Mitchell said.

“ATSB transport safety investigators can also use ADS-B data to help build a detailed picture and better understanding of an aircraft’s flight path* and performance in the lead up to an incident or accident, which can lead to better safety outcomes for the aviation community.”

The precise positional data available from ADS-B can also assist in managing life-saving search and rescue (SAR) operations undertaken by the Australian Maritime Safety Authority (AMSA).

“ADS-B data is another valuable tool used for SAR operations in Australia which helps to improve our ability to save lives,” AMSA’s Chief Executive Officer Mick Kinley said.

“For aircraft in distress, that are equipped with ADS-B, AMSA’s Joint Rescue Coordination Centre Australia will use the aircraft’s ADS-B data to refine a distress location and provide enhanced traffic conflict data in a search area that may involve multiple SAR aircraft.”

The ADS-B rebate program will be open until 31 May 2023 or until funding is exhausted, whichever occurs first.

For more information, including on how to apply, visit https://business.gov.au/grants-and-programs/automatic-dependent-surveillance-broadcast-rebate-program.

It would seem that the ATSB is now actively in the game of Government promotion of aviation rebate programs and the area of transport safety education - I thought their primary role was to be the independent Federal transport safety investigator in the areas of rail, maritime and aviation??   

However what really riled me about this bollocks blurb was the pic that accompanied the release and the explanatory footnote:

* The above Google Earth image was generated by ATSB transport safety investigators using ADS-B data to show the flight path of Bell UH-1H helicopter, registered VH-UVC, which lost of control and collided with water 5 km south-west of Anna Bay, New South Wales, on 6 September 2019 (AO-2019-050).

    

So the big advantage for any operator/aircraft owner taking up the ADS-B rebate (for the ATSB at least) is that they (Big Brother) will be able to effectively track the final moments of your time on this earth when you have your fatal CFIT accident - 

MTF...P2 

[Kharon]

It is an old drum; but a good one.

It's worth taking a moment to read 'Cloudee's' post on the UP _HERE_.

"A coroner examining the 2018 death of a young pilot says he cannot find anyone at fault following her fatal crash at a mountain range in remote southern Tasmania — but slammed Australia's air safety investigator for its "worthless" investigation of the tragedy."

I wonder; now this could just be a one-off bark by a Coroner having a bad case of flatulence on the day. On the other hand, it could, just, maybe, be the opening stanza of something much more valuable. There is long, long line up of Coroner remarks and open dissatisfaction related to aviation deaths. Victoria has had it's fair share lately and will keep the Coroners enclave busy for a while yet.

We all do it, in the pub after work; during a break or at the end of a shift; discuss the latest item of interest and voice our opinion. I imagine that within the realms of the Coroner, with certain restrictions, there may be a similar amount of general 'discussion' - perhaps not related to specifics - but to 'general' common features. Items like the ATSB reports for example. I know I get fed up reading the ATSB reports, when they finally emerge from the sheltered workshop. Trying to convert those reports into something of value toward prevention of a repeat is essentially a waste of time and effort. It must be frustrating for the Coroners; there is long history of their recommendations and input being dismissed or denigrated by the aviation authorities (and that is a historical fact).

Take the Essendon DFO event for a classic, ranked up there with Lockhart River, or even as far back as the Seaview event. How is the Coroner to make a decision without 'all' the facts being presented in the report. How does a Coroner deal with that which is not mentioned, particularly when much is swept under the carpet. The Coroner can only deal with that which is presented or can be determined; but what of the background 'noise'; that which is not investigated and yet may have some relevance.

Questions - for instance; why was Hood, not a qualified investigator on the Essendon scene in record time; did he contaminate the 'scene'? Was his first encounter with burned bodies traumatic to the extent that his judgement was impaired? How extensive was the examination of the pilots medical history and general background post event? Does the Coroner realise that at ingrained habit of all multi engine pilots in the King Air class of aircraft is keep a hand on the power levers throughout the take off; apart from the five or six second it takes to retract the undercarriage? Or even why an experienced pilot would not spot an out of trim condition before the speed indicator was off the peg? To me it seems that these and other items (like the Mayday call-outs) are relevant to the Coroner's thinking. Not mentioned. - But I digress.

The case in point is the event in Tasmania; yet another CFIT. This type of accident is way up on this list of 'repeat' events; nearly all fatal. ATSB are now waving the ADSB flag as a 'cure-all'. Of course this is 100% proof snake oil; ADSB would be of no value to either the Essendon or the Tasmanian pilots; non whatsoever. (MTF on this).

Aye well; this Coroner may just have has indigestion - the mini rant soon forgotten and glossed over; his report about as much use as the ATSB's in preventing a repeat performance where low cloud and high terrain meet the unfortunate. How many has this killed in the last few years and what has ATSB done to reduce the toll?

"Similarly, the Coroner cannot determine civil liability, although the Coroner’s finding may be relied upon in subsequent civil proceedings and/or insurance claims."

Toot - toot...;

[P7_TOM]

If you go out in the woods today.

Before you launch, please consider two very important items; to wit, Page 10 par 41 of the Coroners report into the Par Avion BN2 CFIT event in SW Tasmania; and the consequences of 'unforgiven error'.

The take a close careful 'examination' of exactly what the BoM forecast is 'actually' trying to tell you. It is, IMO, absolutely essential that you fully comprehend and translate to the proposed route, the words and music provided.

The Coroner's report is a fairly light weight read; not overly legalistic nor complex. For the connoisseur, the part related to the ATSB 'tick and flick' report on the accident is worth the time and consideration.  Page 14 : para 61..Page 16 : paras 69 - 76 in particular. The remarks made are mild enough, but accurately touch on the 'attitude' we see so often witness in other reports; and, importantly reflect many, many other remarks made by Coroners over the years relating to the ATSB reports and 'conclusions'. I could bang on about it; but its all been covered and documented so many times now, why bother. We need a top dog who is actually qualified, free of the MoU and prepared to get 'stuck in' and provide the evidence, advice and conclusions so essential to preventing repeat performance.

Actors and singers get 'encores' - pilots do not - Page 10 - para 41 - is what happens when high terrain, low cloud and those who will never grow old meet. Think on..

[Peetwo]

A point of comparison??

Slight drift but I think it is important. Reading back over the media reports, seeing the pictures, then reading the Coroner's report (multiple times) and then referring to the ATSB report - AO-2018-078 - for some reason drew me back to a very sad point in time, when a former work colleague and friend, Cheryl Hicks was killed in a BN2 accident at Coconut Island in the Torres Strait -   

This got me then looking up the BASI/ATSB report for that terrible accident - ref: https://www.atsb.gov.au/publications/inv...00220.aspx  

ANALYSIS
The flight apparently proceeded normally until late final approach when the pilot initiated a go-around because of a vehicle on the airstrip. There were clear indications from the wreckage examination that the aircraft was rolling and yawing left at impact. The status of the left engine at impact logically supported such aircraft behaviour. While the witness description of the aircraft initially veering left also supported this conclusion, the report that the aircraft rolled right immediately before impact did not. In the asymmetric power and low speed situation that existed, it was most unlikely that the aircraft could have rolled right. On balance, therefore, the direction of roll as recalled by the witnesses was incorrect.

Whether the vehicle entered the airstrip during the latter stage of the aircraft's approach, or whether it was on the airstrip and the pilot expected it to move, was not determined. However, the position of the wing flaps at impact suggested that the pilot had selected full flap, and that the flaps subsequently did not move from this position. This implied that the pilot had been committed to land and that the aircraft speed was at, or less than, 65 kts.

Under normal circumstances, a go-around with both engines operating would have been a relatively basic procedure for the pilot to conduct. Because there was no apparent earlier action or radio call, it is unlikely that the pilot was aware of an asymmetric engine condition until the go-around was initiated. When the asymmetric power condition arose, the pilot's task was complicated by a number of aspects:

1. the aircraft was at low level, and probably low speed, when the go-around was initiated. This would have provided minimal opportunity for the pilot to lower the nose of the aircraft to increase airspeed and hence aircraft controllability;
   
2. depending on the exact position of the aircraft when the go-around was initiated, the pilot may have had to manoeuvre away from the sand dune and coconut palms on the southern side of the strip;
   
3. the pilot had to deal with the control forces associated with the asymmetric power condition, in addition to those associated with the engine power increase;
   
4. to retract the flaps to the take-off position, feather the left propeller, and adjust the elevator and rudder trims would have required the pilot to fly the aircraft with her left hand while conducting these other tasks with her right hand. Completion of these tasks may have been difficult, if not impossible, in that control of the aircraft may have required the pilot to use two hands on the control yoke to overcome the out-of-trim forces;
   
5. the pilot's stature, seating position as altered by the cushions she normally used, and the position to which the rudder pedals had been adjusted, may have affected her ability to manipulate the aircraft controls to the extent necessary to maintain control of the aircraft;
   
6. at a speed of 60 kts, the aircraft would have taken about 7 seconds to travel from overhead the witnesses at the eastern end of the island direct to the impact position. While the actual aircraft track was not established, this timeframe was probably indicative of the period available for the pilot to recognise the situation, evaluate available options, decide what action should be taken, and initiate that action; and
   
7. the north-westerly wind would have exacerbated any tendency for the aircraft to drift left as a result of the asymmetric power situation.
   

These influences would have placed the pilot under an extreme combination of workload and stress and may have affected her decision-making and flying ability.

An alternative course of action available to the pilot was to overfly the vehicle and land the aircraft on the remaining section of strip. Another was to reduce power on the right engine and conduct an emergency landing on the tidal flat area. However, without accurate information concerning the position and altitude of the aircraft when the go-around was initiated, no positive conclusions could be drawn concerning these options.
Wreckage examination
The pre-impact position of the carburettor heat controls for both engines could not be positively determined. It is possible for ice to have formed in one carburettor and not the other. If ice was present in the left engine carburettor during the approach, it was unlikely to have been evident to the pilot because the engine was probably operating at low power. Such a condition could have caused the engine to fail to respond at the commencement of the go-around. Because of the salt water corrosion damage, it was not possible to assess the pre-accident condition of the carburettor. It is also possible that aggressive throttle operation by the pilot at the commencement of the go-around could have affected normal engine operation. In summary, there was insufficient evidence to reach a positive conclusion concerning the operation of the left engine.

Examination of the aircraft wreckage did not reveal any evidence to link the circumstances of the accident with the defects listed in ASR 111642, or those subsequently rectified on 2 January 1999. Further, no evidence was found of any aircraft unserviceability being reported and/or recorded between 2 January and the accident flight.

---

SIGNIFICANT FACTORS

1. The pilot initiated a go-around from final approach because of a vehicle on the airstrip.
   
2. The left propeller showed little evidence of rotation damage. The reason for a possible loss of left engine power could not be determined.
   
3. For reasons that could not be established, the pilot lost control of the aircraft at a low height.
   

---

SAFETY ACTION

As a result of this occurrence, the Australian Transport Safety Bureau (formerly BASI) is investigating a possible safety deficiency 19990038 that relates to the security of airfields in the Torres Strait against public access.

Any safety output issued as a result of the analysis of safety deficiency 19990038 will be published in the Bureau's Quarterly Safety Deficiency Report.

P2 comment - I'll let those interested make the comparisons but in my honest opinion the two reports are like chalk and cheese. Obviously technology etc is much more advanced but if you consider the 1999 report was completed inside 11 months (compared to over 3 years). Sure it didn't have any flash drone pics or ADS-B tracking but it also was not opinionated or overly speculative. IMO the average subject matter reader, without making too many speculative assumptions, reading between the lines can fairly quickly make their own conclusions to the causal chain and take onboard the lessons that came from this very sad tragedy - RIP Cheryl!

MTF...P2 

[Kharon]

Shall I compare thee to a summer’s day?

P2 comment - "I'll let those interested make the comparisons but in my honest opinion the two reports are like chalk and cheese."

Correct; bang on in so many ways. The first noted difference is in the time scale between event and report. Eleven months - granted, it was a fairly straight forward event to investigate and, according to legend, the real delay was in waiting for the surviving passenger to make a definitive statement, to wit: there was an unattended  truck parked on the runway. Without fluff or fuss, the report covers all the bases needed, offers some alternative course of action for those facing a similar situation (stock for example) and a short sentence on the possible 'influences' on decision making. Succinct, to the point and; importantly of value to the reader.

One of the stark differences is in the complete lack of 'background data, related to the operator and the 'safety' system in place. Read the Ross Air report or the latest CFIT report - the sheer verbosity and 'fluff'' ploughed into the 'meat and spuds' of the events is mind numbing. The lack of useful 'I learned from that' stuff is remarkable.

In the short report from BASI there is a few clear messages; no fluff and 'data' to plod through - just the facts, an analysis and something to think about should the reader end up in a similar situation. Things appearing on the runway is not a once in a lifetime event; neither are go-arounds, routine stuff for lots of operations and, believe it or not - things can go wrong. This BASI report IMO achieves the desired outcome, it makes aircrew aware that until you are signed off and in the pub; it can all turn to worms, in a heartbeat.

The latest epic from ATSB into the CFIT in Tasmania takes a long while to make a simple point - VFR into IMC is nearly always a lethal game when played in valleys surrounded by high terrain; there is a long list of those who played and lost. It should not take 100 pages and three years to promulgate a simple message or even two. Be prepared to go-around at any tick of the clock and don't fly into valleys - unless you are sure you can get out at the other end - or the backdoor is unlocked. Time, money and effort wasted in laying or shifting blame and justification of 'policy' instead of focus on the real messaging - "Warning - this can kill you".


"Aviation in itself is not inherently dangerous, But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect."

Toot - toot...

[Peetwo]

Comments in response to TAS Coroner's condemnation of ATSB report -     

Via Linkedin:

Ben Cook• Following Director, Human Performance and Safety at Royal Australian Air Force (RAAF)1w • 1 week ago

Another very disappointing outcome for an ATSB accident investigation report, particularly given the previous extensive and independent review of the ATSB as an outcome of the Pel Air (Norfolk Island ditching) accident report. Taxpayers and grieving families deserve better.

Australian Federation of Air Pilots (AFAP)
4,902 followers
2w • Edited • 2 weeks ago
Follow

RIP Nikita Walker - The coroner's inquest into the death of a "talented and conscientious" pilot failed to establish why her aircraft crashed into a mountain but heavily criticised Australia's air safety regulator (ATSB) over its "worthless" report on the tragedy. ATSB investigations and Coronial inquests operate under different aims and jurisdictions. Importantly, in line with ICAO Annex 13 and Aviation's just culture, ATSB investigations seek only factual analysis and do not exist to assign blame in any way. #safetyculture
https://lnkd.in/gbAVnUPA



Young pilot was 'trying to find a break in the weather' before crashing into mountain

And from AOPA OZ:

Aircraft Owners and Pilots Association Australia
25 August at 2024
 
TASMANIAN CORONER SLAMS ATSB REPORT AS "WORTHLESS"

The Australian Transport Safety Bureau (ATSB) and the quality of its accident reporting has been brutally criticised by Coroner Simon Cooper in his findings into the 2018 death of pilot Nikita Walker in Tasmania.

"In short, the ATSB report was of so little use as to be, from my perspective, in the performance of my obligations under the Coroner's Act 1995, worthless. I have no regard to it, other than in a general sense, and specifically disregard the findings it contains.", Coroner Simon Cooper.

AOPA Australia CEO, Benjamin Morgan; "the coroners assessment is a clear indictment of the ATSB and a powerful vindication of the concerns that AOPA Australia has expressed across the past five years,
"It's time for a major clean up of the ATSB so that trust in their reporting can be restored,
"Our association and our national membership extend our heartfelt sympathy to the family, friends and co-workers of the pilot." he said.

BENJAMIN MORGAN
Chief Executive - AOPA Australia
Mobile: 0415 577 724
Email:  ben.morgan@aopa.com.au

MTF...P2 

[Peetwo]

Essendon DFO cover-up: An update on the update - It's all in the TITLE?? 

Via Popinjay central...

Update published 1 August 2022

The ATSB undertook a significant review of the available material and sourced additional evidence from organisations in Australia and overseas following the circulation of a draft of the report to Directly Involved Parties in 2019.

Additional work was considered necessary when changes were made to the design of surfaces at Essendon Fields Airport that manage the location and height of buildings in proximity to runway 08/26. These changes were made by the aerodrome operator around the time the draft report was released for consultation. The changes were advised in update 1
The investigation has involved consideration of historically complex subject matter with the application of both Australian and international aerodrome design requirements dating back to the 1970s. The ATSB has applied considerable effort to understanding the application and function of those aerodrome design requirements from the 1970s to the present in the context of changes at Essendon Fields Airport. It has taken the investigation time to overcome the challenges of limited information available from historical periods to provide context to the investigation.

The title for this investigation has been updated to ‘Aerodrome design changes and the Bulla Road Precinct development at Essendon Fields Airport’ to recognise the scope of matters the investigation addresses.

A draft of this report was released to Directly Involved Parties for review on 15 August 2022. Directly Involved Parties have 60 days to provide comment to the ATSB. A final report is expected to be released publicly in the last quarter of 2022.

This was the thread post (above) that contained the original 'Update 2': Popinjay's spin'n'bulldust on YMEN DFO investigation 4+ year delay?? 

This was apparently (at least) updated on the 25 August: 

Last update 25 August 2022

  
Hmm...doesn't that make it (at least) update 3? Wonder if we will get an update at the end of the DIP process on the 12 October??

MTF...P2 

[Kharon]

The Unacceptable from the Unspeakable.

ATSB - “The investigation has involved consideration of historically complex subject matter with the application of both Australian and international aerodrome design requirements dating back to the 1970.”

BOLLOCKS.....

"DFO Essendon is in the Melbourne suburb of Essendon Fields, approximately 11 kilometres (6.8 mi) north of the Melbourne central business district. It opened in October 2005."

What in the name of best Kook-Aide is the bearded Popinjay supping on now? This is supposed to be a 'safety inquiry'; the 'context' of which should have been decided and promulgated donkeys years ago, ICC appointed and approved – not an 'audit'  - end of...

The 'safety case' seems simple enough to most; in 1970 there was were no close in 'tall buildings' then, not even considered.– well you know the history – millions made and the aerodrome land and surrounds raped.

But the real issue, the elephant on the runway is the DFO and the approval process. Did the construction impinge on ICAO mandated 'safety zones' or did it not? In short, was the thing legal under the rules at the time? Have rules been manipulated since to accommodate vested interests since? Nothing whatsoever to do with 1970 -

Whether Quartermain would/could have extricated the aircraft from the event had the DFO not been there is academic. The point is,  it was there and he hit it.

Why have the ATSB not done a forensic investigation into the pilots past actions, particularly the event at Mt. Hotham and his 'true' medical condition; opinion related to the 'May-day call outs etc.. Something went very, very wrong that day – and the bullshit Hood spouted about 'full left rudder' being the take off trim setting does not pass the Pub test; not in the opinion of over 50 Be200 pilots with a total (collective) time on type in excess 100,000 hours.

Why are ATSB so desperately playing for time and combing ancient clauses, those  consigned to the basement and rats, instead of asking the basic questions? – Who gains, who profits and who losses from the approval, the construction and the happy hearse-feathers from them leading the parade down the long, winding road to perdition. The bomb landed on the ATSB desk – the mutt running the show is desperate to get out from under; someone has to catch the bomb – and the wee bearded Popinjay is the blustering fool stood directly in the bulls eye. Aye; its not all bad news then, is it children..

Tick Tock... tick-tock says the DFO clock...

[Peetwo]

The search 4 IP remains elusive in the hands of Popinjay - 

Via Popinjay central:

ATSB streamlines accident and incident reporting requirements

[b]

The Australian Transport Safety Bureau anticipates amendments to the Transport Safety Investigations Regulations (TSI Regulations), which detail the requirements for reporting transport accidents and incidents to the ATSB, will take effect on 1 January 2023. 
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“The TSI Regulations set out the ATSB’s safety occurrence reporting scheme and prescribes what occurrences must be reported to the ATSB, the ‘responsible persons’ who are required to make a report, and the particulars to be included in a report,” said ATSB Chief Commissioner Angus Mitchell. 

The changes predominantly relate to the aviation industry. 

“For aviation there are two key changes being introduced in the amended regulations – the creation of four categories of aircraft operations, each with different reporting requirements, and new requirements for sport aviation bodies to report accidents and incidents to the ATSB,” Mr Mitchell explained. 

The four categories comprise Category A (passenger transport), Category B (commercial non-passenger, including medium to large RPA), Category C (non-commercial) aircraft operation, and Category D (small non-excluded RPA and certain uncrewed balloons) aircraft operation.  

“Higher categories, in particular passenger-carrying and commercial operations, will have a greater reporting focus due to the greater public safety benefit that could be derived,” said Mr Mitchell.  

“Non-commercial aircraft operations and uncrewed RPA and balloons will have lower reporting requirements.” 
The Regulations define occurrences that must be reported to the ATSB as “immediately reportable”, which must be reported by telephone as soon as reasonably practical, and “routine reportable” matters, which can be notified to the ATSB by a written report within 72 hours. 

“Changes to the regulations ensure immediately reportable matters are those more likely to be considered for investigation by the ATSB, while reducing the reporting requirements on industry for those matters the ATSB is less likely to consider for investigation,” Mr Mitchell explained. 

Other changes to the Regulations include aligning aircraft operation categories and definitions with CASA flight operations rules introduced in December 2021, and aligning definitions of aircraft accident, serious aircraft incident, aircraft incident, fatal injury and serious injury with International Civil Aviation Organization definitions 

“Changes to the regulations also simplify reporting requirements for industry by removing prescriptive lists of individual kinds of occurrences and defining these concepts more broadly.”  

Reporting will be based on more general concepts including accidents, serious incidents, incidents, loss of separation and declaration of emergency. Guidance on the ATSB website and to be provided in the Aeronautical Information Publication details comprehensive examples of type of occurrences that fit into each. 

The ATSB consulted extensively with industry on the proposed changes over a five-week timeframe between January and March 2022. Feedback received during that process was largely positive, and helped shape the final Regulations package. 

The amendments have now been approved by the Minister for Infrastructure, Transport, Regional Development & Local Government, and have been proposed to the Executive Council for endorsement in coming weeks. The amended Regulations and new reporting requirements would take effect from 1 January 2023.  

“Reporting to the ATSB is a simple and quick process,” Mr Mitchell concluded.  

The ATSB is also updating the reporting forms on the ATSB website to make reporting even easier. 

“Nonetheless we do recognise the aviation industry has been through a period of considerable change and disruption in recent years and do stress that our approach to implementing these amended regulations is focusing on education and encouraging better reporting practices over an extended period, with less emphasis placed on compliance particularly for industry participants who may not be fully across the new requirements.” 

Aside from being the basis for starting safety investigations, all occurrences reported to the ATSB are maintained in Australia’s official aviation occurrence database and used for safety research and analysis.  

“Ultimately all of aviation benefits from an open and trusted aviation occurrence reporting framework.” 
Click here for more information.

Plus via the Yaffa:

ATSB streamlines Reporting Requirements

5 October 2022


The Australian Transport Safety Bureau (ATSB) this week announced new accident and incident reporting regulations based on four categories of operation.

The amendments to the Transport Safety Investigation (TSI) Regulations are due to come into force on 1 January 2023, and establish a scale of requirements from high-capacity RPT down to uncrewed balloons.

"For aviation there are two key changes being introduced in the amended regulations – the creation of four categories of aircraft operations, each with different reporting requirements, and new requirements for sport aviation bodies to report accidents and incidents to the ATSB,” explained ATSB Chief Commissioner Mitchell.

“Higher categories, in particular passenger-carrying and commercial operations, will have a greater reporting focus due to the greater public safety benefit that could be derived.

“Non-commercial aircraft operations and uncrewed RPA and balloons will have lower reporting requirements.”

The four new categories are:

• Category A – Passenger Transport
  
• Category B – Commercial, non-passenger including large remotely-piloted aircraft (RPA) and training
  
• Category C – Non-commercial aircraft operations, including private GA
  
• Category D – Small, non-excluded RPA including certain uncrewed balloons.
  

The new regulations define incidents and accidents as either "immediately reportable" or "routine reportable" based on the category into which the incident or accident falls.

"Immediately reportable" means as soon a practicable by phone. "Routine reportable" means a written report within 72 hours.

“Changes to the regulations ensure immediately reportable matters are those more likely to be considered for investigation by the ATSB, while reducing the reporting requirements on industry for those matters the ATSB is less likely to consider for investigation,” Mitchell said.

Among the changes is a switch from a prescriptive list of accidents and incidents that need to be reported to a broader definition of reportable occurrences.

According to the ATSB, the new regulations follow an extensive consultation period in January-March this year, which has been described as "largely positive" and has helped to frame the new regulations.

"Nonetheless we do recognise the aviation industry has been through a period of considerable change and disruption in recent years and do stress that our approach to implementing these amended regulations is focusing on education and encouraging better reporting practices over an extended period, with less emphasis placed on compliance particularly for industry participants who may not be fully across the new requirements,” Mitchell said.

More information on the new reporting requirements is on the ATSB website.

Here is just one comment (from a SME) in reply to this Popinjay announcement...

"..Wow, those geniuses come up with 4 categories to fit the industry into. There must be award night coming to celebrate this ground breaking work!

What would be good is to elaborate on why they choose to investigate, and what ideology they use to determine the "contributory factors"? Where does the "Influence & Effect" analysis stop? That's opinion, not evidence.

I'm leaning back to the old NTSB method of "probable cause". This would remove the "magic" of what contributes, and help people like the Tassie Coroner and industry to learn from accidents. The "Crash Comic" from the DoT days did it well and we all learnt something.

These days it seems virtually anyone who works in an outfit, contributed to the prang.

If they want to stick with their current format, maybe "possible contributory factors" would at least help.  The Coroner touched on this.

It's difficult to learn anything with the current format and it adds to the complexity, cost and confusion in the industry. Bureaucracy creating more bureaucracy, and this is improving safety? Angel Flight is a good example..."

From the feedback I've read so far (the above) is a general consensus from the IOS and BRB...

MTF...P2 

[P7_TOM]

Thought this post from K worth a bump.

Tom's Eagle. (A twiddle)..

I don't imagine that the 'subject' will ever be included in a pilot training syllabus; or, if the folk law and general practice can ever be formalised into a comprehensive format. There is a good case to support this notion, the cost of producing a manual or even a short video probably on a par with the cost of the time the ATSB commissioner wasted rabbiting on about a simple matter of a bird strike and an out of control 'drone'. If you need a 'headline' case to prove the pudding, note the silence surrounding the increase in TIBA operations and the 'look-at-me' blather spouted over what are 'routine' events. But, although unintentional contact with 'wild life' can and does cause the odd problem or two (look no further than 'Sully' and his encounter with wildlife _HERE_) I can't see why some form of 'advice' cannot be made generally available, as part of 'improved' hazard awareness. It beats seven bells out of meaningless twaddle in the media. The FAA have taken the 'problem' seriously enough and are doing something about it – HERE_.

Strange as it may seem to city folk, there are many varieties of local wild and domestic life which can really spoil your day; they are part and parcel of every day life in the air, particularly to non scheduled operations into minor airfields. Statistically, contact events don't rate as a 'major' threat, which probably explains why the 'subject' has never been formally recognised; but the results of a chance meeting can be lethal at worst, costly and scary at best. The potential for an 'incident' comes in two flavours; land based and airborne.

Land based are probably (on balance) the most lethal; but also the rarest. Two 'busy' times for those flying – early morning take off into the sun/ mist/dust /rain and evening, just on dusk landing into crepuscular light, dust and fatigue an element. Two or three Kangaroos belting across the runway at 20 knots as you thread the needle between first and last at speed (surface, brakes and nose wheel?). Cattle that just wont move. especialy when fuel is low and night is approaching; donkeys another cunning, hard to see road bump that will seriously spoil you day. Yes, we have stock fences, mostly well maintained but animals are not as dumb as some would have you believe; not by a long shot they ain't. Chances of a close encounter, in the bush, higher than you may think. We ran some numbers from 'non scheduled' operating days: a 'Jesus saves' event once in every 5,000 hours; a 'Duck me' moment once every 1500 hours and a 'would ya look at that' event just a tick over once every twelve month. Statistically insignificant, unless it is you at the wheel.

The airborne group is  (pardon the expression) an altogether different animal. Most pilots can, with ease spot the difference between cow, camel, donkey and kangaroo; and, probably anticipate the actions of either. But knowledge of the 'behaviour' and responses of avian species is limited. It was discussion of Tom's Eagle which kicked off this ramble; well, that and the pompous Popinjay banging on about 'bird strike'. I doubt he could tell a Wedge Tail from a Buzzard if it bit him on the arse. However, it probably matters that pilots have a least a rough working knowledge of the way 'Birds' operate and interact with aircraft. Particularly the larger species; their habitat, habits and 'working patterns'. Watch the Gulls at the beach front working a patch of spilled chips (fries); sure they'll move away, but then – circle back to the food – every time, it comes from hunting, ruthless determination to return, no matter the threat. Proof? Oh, that's easy watch the man at Mascot with the shot gun; he blasts away, the Gulls bugger off – he departs the fix and back troop the birds. You can almost imagine the conversation - “he's back Gladys, best round up the kids”  “honestly Charlie, I don't see why we have oblige this ugly machine and noise every hour or so.” - “Just think of it as rent Dear; mutual preservation; come on, two quick laps of the airfield, just the thing before lunch”...........

But, what of the not so obliging? Things like Wedge Tail eagles, Swans, Pelicans, Sea Eagles, Emu's and half a dozen other 'big birds'. Google remains a stalwart friend; their size, weight, habits and much else is all freely available and worth a quiet hour study. Seeing as how the noisy Popinjay has weighed in on a 'bird strike' and the potential hazard to helicopter operations from Wedge Tails, I thought it may be worthwhile to mention some things Google omits from its worthy information pages; from the pilot's perspective. First item – the bird itself – HERE - .

Item next – as you can see, this is a large 'dark' coloured bird with a very large wing span and pretty easy to spot, on the wing. There it hovers, effortlessly watching for prey you could assume; true, but wait, there's more. Nothing in the skies challenges this master of air – nothing; it just ain't scared of you and not about to loose the prime position adopted; often over the same spot – it ain't going to move. See and avoid your responsibility. The bird is hostile to 'invaders' – ask the members of the Darwin model aircraft club (terrific venue) about the carnage as two or three 'Wedgies' decide that the intruder must be seen off; the clumsy attempts to out fly these masters by ground based folk is almost laughable; result – machines shredded, birds doing aerial 'high fives' – wishing they could eat what they've killed.  Pelicans another worthy adversary; once prey is spotted from the circling area - and the dive commenced, it is prudent to move aside. Swans, just after take off accelerating through V2 to V4 will rarely alter course – for some very valid aerodynamic reasons; and, it must be remembered that the 'Cob' is particularly fearless and reluctant to give way to an aggressor.

But I have digressed and probably bored the fellahin rigid; all TOM's fault. It was the yarn of his most treasured acquaintance with Wedge Tail that started this ramble (well, that and his 'observations' on our Popinjay's waffle). Many, many years ago, as a young fellah, TOM flew a regular service into a valley, surrounded by some rugged country. One day he spotted the Wedge Tail (WT) parked at altitude over a prominent feature; effortless and amazing (30 knot headwind that day and 'bumpy' low down). The airframe was 'nudged' over a little to get a better look; there they were – eye-ball to eye ball for a fleeting moment. This became a regular event, much anticipated and enjoyed; but, TOM always 'blinked' first and peeled away. The best part of the yarn is the day he had a visiting travel journalist in the right seat; descending through cloud TOM nudged the journo and pointed to a spot on the wind screen “Watch there” and just as they cleared to cloud base – there was TOM's Eagle in a sunbeam, on time, on station – Good morning old friend whispered TOM as the journo sat in stunned silence – until later - “Wow etc. etc” and that journo never forgot the memory until he sadly passed away, a life long friend, still missed to this very day.

Enough – ramble over; with apologies to those who don't 'get it'..

Toot – toot..

[Peetwo]

Hooded Canary the patron Saint of Oz Transport Safety Investigation?? 

Courtesy of the Australian Institute of International Affairs, via Youtube:

(Caution: Bucket on standby for certain parts of HVH's typically self-aggrandising presentation -  )
 

Making transport safer for all travellers
69 views  May 5, 2021
About the event:
Mr Hood will detail how the Bureau’s investigation process works and how lessons are learned to make the sector safer for all travellers. In an industry where international cooperation and capacity building is critical, he will also discuss the role that ATSB and its kindred Australian organisations plays in supporting capacity building in our Asia-Pacific region and the challenges for the future given the exponential growth in aviation in our region.

About the Speaker:
Greg Hood was appointed to the role of Chief Commissioner and Chief Executive Officer of the Australian Transport Safety Bureau on 1 July 2016. In his time as Chief Commissioner, Greg has overseen a number of significant transport safety investigations and report releases across the three modes of aviation, rail and maritime.  He has also successfully transitioned the ATSB into its new role as the single national rail safety investigator, bringing to a close a commitment to rail reform initiated by the Council of Australian Governments in 2009. Prior to his commencement with the ATSB, Greg held the role of Executive General Manager, Air Traffic Control with Airservices Australia.  In this position, he was responsible for the management of over 1,300 air traffic management staff, providing services for 11 per cent of the world’s total airspace for more than four million flights annually from 28 air traffic control towers and facilities. Greg began his career as an air traffic controller in the Royal Australian Air Force in 1980, serving at locations throughout Australia and in the Middle East.  In 1990, he moved to the Civil Aviation Authority, a predecessor to what is now Airservices Australia. Greg is also Chair of the International Transportation Safety Association.

MTF...P2 

[Kharon]

Have we finally reached ATSB Nadir?

That sudden, abrupt stop: at the end of a long descent into darkness? Perhaps not eh? But it must be close now; how much longer can the free-fall continue before someone, somewhere slams the brakes on and says “Whoa; this close to the pit is close enough.” No children, I'm not joking. Not when you start to add it all up, across the board. Not when one includes 'those who must be satisfied' which means, in reality, that 'they' are safely ensconced; can and will continue to ensure their comfort, safety, jobs, super and pensions. Which, living in the real world, is a very reasonable adult thing to do. BUT, in the real world there are very real penalties for incompetence, for fabrications, for telling faerie stories and for loosing the organisation money; not to mention credibility. For a 'government' (or independent agency), credibility is all – where would they or the politicians be without it?  The point is a simple one; how much longer can the 'un-elected' withstand international scrutiny, before the government are forced to act – in the affirmative? I expect an 'example' is required: in my own clumsy manner, I shall attempt to oblige – for example:-

Start – HERE -. It is a short read; from the ATSB an insignificant dispatch to the 'public' (who will never read it) and the aviation community, who will and shrug: but, perhaps an important side bar to the lawyers assigned to the Essendon DFO case. It is drafted (or signed off at least) by a man who has never even flown a multi engine aircraft – let alone commercially operated the peerless Be200 (Super King Air). Yet he feels free to offer 'advice' on how and what to do in the event the pilot has not tweaked the friction lock on the power levers up to a position where the power lever cannot 'roll back' (a basic 101 at flight school item). Its a BOLLOCKS; complete and utter duckling rubbish; writ large by an idiot with NDI.


B200 Before Take off checks;  NORMAL procedures Section IV (from my book)...


Item 5 - – Trim Tabs – Set.



Item 6 - - Engine controls Friction Locks – Set.

Then, consider the wondrous yarn spun by the unqualified commentator  compared to that of an experienced check pilot; three fail items, before leaving the taxiway. – In primus, the pilot clearly had not conducted the required checks; secondly, why was his hand not in contact with the power levers throughout the take off procedure (apart from three seconds to activate the 'gear up' handle (as per the book) and why, for the love of Mike, would a 'trouble check' be run before the age old call – POWER UP – GEAR UP -  in the event of power failure was not made? (Think on that – problem solved? – Oh, you bet) Yet, logic aside, a quick glance at the power lever position and the slight change in 'noise' would/should/ could alert a professional pilot to the simple fact that his power lever had drifted back an inch or so. Aye; all this a bad enough testament to 'simulator' failure where power levers, obligingly, do not ' 'wander'. But it also speaks volumes about 'attitude' and the 'check training regime. Enough said on that end of the argument – but what of Dr. Godley; he of the the pencil necked comments? Here is the 'sinister' bit – all speculation from me, an opinion if you will. His report (like his 'insight' into Angel Flight') stinks to the high heavens; its rank. The Essendon DFO event, despite Hood's histrionics and nervous breakdown after seeing the carnage aside needs supporting – and how very convenient is the Godley support package to bolster the Hood assumptions of why the Essendon event happened (consider medical history and Hotham perhaps?).  I say this – the ATSB have no idea about what actually happened that day or why; nor are they inclined to dig too deeply into the why and how of either event. No more deeply than Godley has into a power lever drift back caused by a slack pilot who failed to action the pre take off checks and almost stuffed it all up, poncing about. The 'drill' on any low slow engine failure (or roll back) situation demands but only two immediate elements – Power up – Gear up. However with one hand on both power levers (as per universal practice) this 'non-event' could (if it ever really happened) have avoided being used to support a further nonsense. 


Section 6 Be 200:Engine failure after take off:-

1) Power maximum available  - (in lay terms push both power levers forward).

2) Airspeed maintain.

3) Gear UP


There, as per the book – problem solved in a heartbeat – nothing to see - move along.  No report required.  Selah.

Aye; “Never trust the advice of a man in difficulties.”

Toot – toot....................

[Peetwo]

Have we finally reached ATSB Nadir? - Part II

Hmm..why does this sound so familiar??..

UK Air Accidents Investigation Branch investigation (7/2003)

On 23 December 2000, a Beechcraft B200 aircraft departed Blackbushe, United Kingdom to Palma, Spain on a private flight. Shortly after take‑off, the aircraft was observed to bank left before colliding into a factory complex 13 seconds later, resulting in a fire. All on board were fatally injured.

An examination of the aircraft did not identify any technical issues that would have contributed to the accident. However, analysis of the cockpit voice recorder showed a reduction in one of the propeller’s rpm as the aircraft rotated, which would have led to thrust asymmetry. The investigation concluded that, it was probable a migration of a power lever due to insufficient friction being set had occurred. It was also noted that the friction control had been slackened during recent maintenance and it was possible that it was not adjusted adequately by the pilot when doing their checks prior to take-off. As a result of the investigation, a safety recommendation was made to Raytheon Aircraft Company:

The Raytheon Aircraft Company should ensure that reference to the correct adjustment of power lever friction is suitably emphasised in the Beech 200 Aircraft Operating Manual (AOM) and the consequences of insufficient adjustment are not only highlighted in the AOM but also included in the recommended Beech 200 type training syllabus.

The ATSB was unable to find any follow-up action on this recommendation recorded in the investigation site.

To begin, if you refer to the above ATSB link (from AO-2021-034) for the UK AAIB investigation report you will see that you get sent to this PDF report: https://assets.publishing.service.gov.uk...L-7451.pdf -   

The real link for the Blackbushe B200 fatal accident is - HERE or PDF version HERE.

My 1st question is, that given the obvious similarities with the Blackbushe vs YMEN DFO crash, why didn't the ATSB review the UK AAIB final report (refer pg 55-56)? Or did they but for some bizarre reason the ATSB decided to discount because it did not suit their favoured hypothesis?

Ref: https://theconversation.com/lessons-lear...sts-103834

MTF? - Yes much! 

[Kharon]

Probity - As you like it – Or; perhaps not....

This ramble, based on collective opinion was prompted by the 'passing strange' published investigation report, into a seriously 'non-event' sponsored and fronted by Godley, big cheese in the ATSB Goon squad, under the command of the Wee Bearded Popinjay. A pointless report, hardly worthy of media cover, not if taken at face value. So, a pilot's power lever wandered from the desired position – the pilot returned said power lever to correct position, reset the throttle friction and continued on; probably thinking 'must remember that'. It has happened to hundreds of B200 pilots – at least once. So why is ATSB, Godley and crew wasting resources promoting a 'something nothing' event we wonder. In defence of the Essendon DFO build perhaps, timing is all?

There's not too much to 'like' about the investigation of the Essendon DFO event. IMO it has been a shambles from the get go. But, just for the moment lets put the dubious parentage and approval for the DFO monstrosity out of the frame and focus on the crash event. Bear with the ramble while we examine some elements which could, perhaps, be of some interest to the Coroner, those left behind wondering, et al.

In general, most pilots pretty much follow a well beaten track pre departure; check the weather forecast, rearrange flight plan as required, check the weight and balance, order fuel if needs be, erc. Then amble out to do the pre flight checks and prepare the aircraft (more or less). The B200 manual provides a 'Before Engine Start' check list (41 items in my book). Many of which may be checked before loading passengers and baggage; this for practical purposes – a fault in any system is best detected prior to loading. This check list (my book) does not mention 'trim tabs' at this stage, but it does focus on 'cockpit' system. Most pilots would, at this stage at least note the position of both the roll and rudder trim wheels; almost automatic to reset to Zero at this stage.– Bear in mind that the 'after landing checks' (and SOP) call for the trim tabs to be reset to 'zero', after landing – a habit forming ritual. Even then, most pilots would check, as a matter of routine, the 'tech log' first; engineering often tinker, and may not have 're-set' before exiting the cockpit. However, had maintenance been carried out, it would be noted and the tech-log is usually checked first by the crew.

Either way, to any pilot experienced on type any serious out of trim zero setting would, on balance, be spotted while doing the pre-flight. It is probably worth mentioning here that during the pre flight 'walk around' (external checks); checking the physical position of all trim tabs, against witness marks is a written requirement, this to check the veracity of external position indication against the cockpit indicators.. Even so – in my B200 book, the Before Take Off check list also focuses the pilots attention on 'flight controls' and Trim. The elevator control wheel is a large round item, next to the pilots right knee; the rudder trim is directly within the sight line, below and just slightly to the right – can't miss it. But even then, the check list goes on to itemise 'Trim Tabs'. Even to the lay mind, it must by now becoming obvious that any pilot would have a hard time 'missing' a gross miss set of an essential, potentially lethal mandatory check list item.

ATSB report categorically states that there was a gross rudder trim setting error and cite this as the fundamental cause of the event....

For a moment consider the percentage chances of that statement actually being correct. The questions which demand answer have not been examined. The big one is “Why'. With 'how' running a close second. While you consider this, please remember back to flying lesson number one; from that point onwards; for any aircraft flown, the setting of 'trim' and throttle friction has been an essential element; drummed in hard and often. It becomes a deeply ingrained habit, a good one, most essential to not only efficient, safe, comfortable operations, but an imperative during any 'emergency/ abnormal' procedure. Almost a reflex action to any disciplined pilot who has progressed beyond first solo. While on the subject, put your hand up if you have ever forgotten to reset after landing and taken off again shortly thereafter – think back to the speed you where doing on the runway, when the Penny dropped – well below rotate speed perhaps? Anyone with more than a handful of hours in the B200 would pick up a gross rudder out of trim condition at about  40 knots and have it corrected before 50 knots, half a turn is all it needs – remember the rudder of the B200 is a powerful force – it needs to be for OEI operation.

So, this all comes back to the pilot on the day. Was he distracted – did the phone ring; or was there an urgent call from nature during the pre flight interrupting the check list half way through checking the set of the trims? Has ATSB defined why multiple opportunities to note an out of trim condition were not taken; interruption/distraction as a possibility, or was it something else? Like perhaps the trim was set correctly pre flight and impact forces drove the indicator to 'full' deflection. That is a higher percentage chance than an cognisant pilot 'missing' the check. Was the pilot actually 'fit for duty' that day? We still don't know in detail. There is a wide range of 'medical' possibilities, both physical and psychological existing within the ambit of reasonable, reasoned consideration. Should these elements have been exhaustively eliminated as part of the ATSB investigation and presented to the Coroner?

Only my opinion; but one shared by many, those that believe the ATSB investigation into this event needs to be re-examined in detail. It ain't 'wrong' but it seems 'off' somehow. There are several items which raise elements of reasonable doubt to the the interested, experienced reader. The eye-brow raising begins with the mad dash to the crash site by the the then director Hood, he arrived before the smoke and dust cleared – unusual to say the least – the risk of scene contamination just for a start.  Then the adamant pronouncement that the rudder bias set full left was 'the' sole cause; wrong? – No – but way 'off' for a lay down misere. This followed by the bizarre pronouncement that the DFO building was indeed a safety item, of benefit to the travelling public even. For (according to Hood) had the aircraft hit the freeway then the carnage would have been greater – WTD !? Had the event occurred just a little later in the day and hit the building 20 feet lower the carnage would have been horrendous. Definitely 'Off' – a safe bet there.. The whole investigation seems to have been 'cack-handed' particularly when compared to the British and American examinations of 'similar' events. Then there is all the fuss about the timing of the report, the delays, the obfuscation about the DFO approvals and endless 'legal' speculation on runway width safety zone impingement. When you listen to Senator's questions in Estimates, one of the glaring sleight of hand answers confounds the Questioner; but not industry experts. The questions surrounded the mandatory 'safety zones' required each side of operational instrument runways. The 'Splay'. The glib, answers easily brought the Senators to a point where, for lack of wider knowledge, they were fobbed off with take off and landing vertical 'margins' – i.e straight ahead, but the requirements for mandated 'width' of 'safety zones' was neatly avoided. There is a case to answer right there, make no mistake about it..

Nearly there; last, but by no means least we must consider the pilot. There are three items of note which seem to have been 'eliminated' from the ATSB investigation. Both Coroner and legal Eagles would be well served by requesting and requiring some 'medical' opinion; even if just to eliminate these elements 'from our enquiry' - so to speak.

At least two independent physiological and psychiatric opinions must be provided for consideration. (If it was my call, I'd have the autopsy revisited to boot). I make this remark after conferring with over twenty experienced Check pilots, Chief pilots and highly experience flight crew. I have also canvassed to subject with two highly qualified medical men and one very astute medical lady. All considered it important (given the events on the day) that a full history across the medical disciplines would be beneficial to inquiry; beginning at least two years prior to the incident at Mt Hotham. For it was that day which should have rang a lot of large bells, very loudly.

Revisit the Mt Hotham event. In the beginning was the proposed charter operation to Mt. Hotham; quite complex involving several aircraft arriving within a given time frame at a non controlled aerodrome, within a given set of arrival times. Routine, just another day in a charter pilot's life. The events at Hotham were, to say the least, very concerning from an operational standpoint. It is reasonable to say that most Chief pilots would have grounded the pilot immediately after landing. While the list of 'errors' is troublesome; the reasons for persisting with the flight path flown that day are alarming. Disoriented and quite probably 'lost' with traffic overhead and below, in cloud, over mountainous terrain; 99.9% of professional pilots would have climbed to a lowest safe height, gone a distance away (clear air), let the holding aircraft land, take time to compose both heart and mind and returned to execute the approach as specified. Quartermain persisted in what I consider a very dangerous exercise, endangering not only his own command, but other aircraft and the passengers within. That, stand alone demands serious attention and considered expert opinion on residual mind state at the time of the DFO event. Then there is the physical condition of the pilot to consider – medication, reason for same, side effects, fitness to fly, etc.

Then consider the Essendon take off and subsequent collision with a building that should never have been placed where it is. Was the building 'complicit' or at least a contributing factor to the deaths? Perhaps there was a fighting chance for the pilot to recover the aircraft, given a little more clear air within the boundaries of the runway as they were before 'manipulation' shifted to odds.

Lets look at the aircraft track from zero to collision and consider the actions of the pilot from the 'cleared for take off' – to the full stop on the roof of the DFO. Consider the time line. Start the clock:-

“Cleared for take off etc..

Ok – here we go, hand on BOTH power levers – power increasing – all good 40 knots and “bugger me” we are off the centre line; now count ::100, two hundred; three hundred – most pilots would have by the end of that count, checked the whole flight system; engines reading correctly; trims set (Uh-Oh) lots of right leg required (50 Kts) rudder trim out (reset) 60 Kts back on centreline – no bells and whistles – V1, Vr and off we go to Golf.

So why was one of three reasonable options not actioned? 1 – Abort – power off, brakes on, exit runway return to base. 2 – Engine not performing; abort. Repeat the above. 3- Left rudder trim hard over – reset and continue perhaps. But no; just an increasing loss of control and multiple Mayday calls from airborne, right until the bang at the end of the short journey.

Did all the holes in that famous slice of cheese line up? Technically, they did. But to me, it seems the 'official' knitting became unravelled long before the final stanza was played. Humans are fragile creatures, was this pilot subject to things beyond his control or knowledge; did a flash back to Hotham freeze his reasoning faculties? Did he have a 'brain bleed' '? Was his medication (if any) in some way connected; could he have recovered if not for the DFO obstacle?. We just don't know; but one thing is absolutely damned certain. There has been a hanger full more money, time and effort spent in an attempt to deny that the DFO was, in any way, shape or form, parked in the wrong spot than poor old Quartermain has had lavished on defining exactly what went wrong that day and why. A lesson denied? A report as left hand biased as the alleged rudder trim was? Some folks died that day; it could have been worse, a whole world worse and yet the DFO still stands, all legal and correct they say; I wonder....

Ayup...Add it all together and ask was there a clearly defined pathway to the inevitable future incident or accident. I just don't know; but had I been his Chief pilot it would be a long, long while after Hotham before I turned him loose, unaccompanied. Even then, before that he'd have to get through the Devil's own check ride after medical evaluation (mind and body). It is a wonder CASA let it all slide away as easily as it did; just another small wonder of the many.

Now the Brits lost a B200 at Blackebush; the flight path, time frame and result equal to our homegrown version. The Brits nailed it; tick, correct answer. Australia's ATSB grabbed the first straw on offer indicating 'pilot error' and neatly, but elegantly shot themselves in the nether regions (their arse for the unlettered).

My venerable, ancient Pelican (Grumble to us) came up with a ripper suggestion;  verbatim I do quote it.  “What if Old mate shoved on the coals and then spotted the misaligned rudder trim; took his paw off the taps to adjust that and the throttle drifted back – brain fade – Hotham flash back – brain crash - May day – no valid escape route or remedial action due to lack of cognitive action”. Not too bad a notion is it. Then there's P7's question - “was the rudder trim hard over setting created by the impact forces, it is only a mechanical link system, a good wallop in the right place could have forced mechanical linkages in that direction”. We just don't know; but the Brits report made 'good sense' – the American reports are credible – the ATSB version; not so much. Perhaps the ever increasing lack of operational credibility (see Pel Air, MH 370 and Angel Flight) has influenced that notion; perhaps; but whatever is influencing ATSB reporting on fatal accident needs to be gone; tout de suite – and the tooter the sweeter, in our most humble opinion.

End of opinion piece – I shall now return my thumbnail to the tar pot. But I say ATSB has become a thoroughly dysfunctional outfit. No longer fit for any purpose bar providing top cover and credible deniability for those very, very few who need it. Like those who know the DFO needs to be demolished but dare not acknowledge it – lest the rice bowls are taken away.

That's it.

Toot – toot.

[Peetwo]

Popinjay...err not to investigate?? 

Example 1, via Oz Aviation:

26-YEAR-OLD QANTAS DASH 8 CATCHES FIRE AT SYDNEY AIRPORT

written by Liam McAneny | November 9, 2022



A Qantas Dash 8-200 caught fire at Sydney airport on Tuesday shortly after landing, leading to 24 passengers evacuating via its front stairs.

The QantasLink Flight 265 had just arrived from Lord Howe Island at 5:40 pm on Tuesday, 8 November. Smoke was seen billowing from 26-year-old VH-TQS’s rear tyres before flames erupted on the rear tyres of the aircraft.

Emergency services arrived at the scene and extinguished the fire shortly after those on board were evacuated.

No passengers were injured in the incident, with many appearing relatively unfazed during the evacuation in footage posted to social media.

QantasLink CEO, Petrea Bradford, said, “Passengers on a flight from Lord Howe Island to Sydney were evacuated following reports of flames near the tyres after the aircraft had landed safely.

“We appreciate this would have been unsettling for passengers, and we thank them and our crew for evacuating in a calm and orderly manner.

“Airport fire crews attended, passengers will be bussed to the terminal, and engineers will inspect the aircraft.”

Despite the fire, reports confirmed that there was no smoke in the cabin and no medical services were required by passengers, despite paramedics arriving at the scene.

The incident comes just a week after Qantas was labelled ‘the spirit of disappointment’ by Choice.

The airline was handed a ‘Shonky’ award for its sub-par performance over the past few years, according to the consumer watchdog group.

Example 2, via the other Aunty:

Glider pilot 'loved soaring flight' as tight-knit community devastated by mid-air crash

ABC Sunshine Coast / By Owen Jacques, Jessica Ross, and Meg Bolton

An 80-year-old pilot who died after a suspected mid-air collision between his glider and an ultra-light aircraft was a man who "loved soaring", friends say as investigations continue into the crash.

Key points:


Police believe an 80-year-old Caboolture man and a 77-year-old from Glenwood were killed when a glider and an ultralight aircraft collided yesterday afternoon

Gliding Australia's safety manager says such incidents "shatter lives, families, and morale"

The Forensic Crash Unit is investigating

Caboolture man Christopher "Bob" Turner was controlling the glider just before 3pm yesterday when the two aircraft came into contact and crashed to the ground at Kybong, near Gympie.

He and fellow pilot Barry Irvine, 77, did not survive.

Their deaths sent waves of sadness across a tight-knit aviation community around the country.

Mr Irvine's family issued a statement today.

"Barry, a talented musician, lived his life to the fullest and flying was his passion for many decades," the statement reads.


Barry Irvine died in a crash at Kybong on Wednesday. (Supplied)

"We extend our sincere condolences to the family of the other pilot involved.

"We would like to acknowledge and express our appreciation to first responders who attended the scene as well as witnesses of the incident and members of the local aero community."

Gliding Australia vice president Lindsay Mitchell said he was shocked to learn of the accident, and said Mr Turner was an experienced glider pilot.


Gliding Australia vice-president Lindsay Mitchell.(ABC News: Laura Lavelle)

"He's flown for decades, and he'd be like the rest of us with gliders. He'd want to be up there looking at those clouds at the moment," Mr Mitchell said.

"He was a very quiet gentleman, very particular, he'd been chief flying instructor at Caboolture Club for a number of years, he'd been an instructor for a number of years, very thorough, very particular."

Mr Mitchell said Mr Turner had stopped instructing in recent years, and said yesterday's flight should have been a run-of-the-mill joy flight.

"He would've gone up there, it was good flying conditions, nice clear air, good thermals," he said.

"He would've just gone up there to enjoy himself." 


Christopher "Bob" Turner (right) has been identified as the 80-year-old Caboolture man who was flying the glider.(Supplied)

Mr Mitchell said the close-knit gliding community was coming to terms with the loss.

"We're just stunned and coping."


It is believed the glider Christopher "Bob" Turner (left) was flying collided mid-air with an ultralight aircraft.(Supplied)

The gliding group's safety manager Drew McKinnie said news of the incident spread quickly, and Sunshine Coast Gliding was a tight-knit club.

"The impact on clubs, families, and friends is massive," he said.

"I have been involved with investigating fatal incidents before.

"It certainly shatters lives, families, and morale.

"My motivation as a safety manager is we have to understand as much as we can about what led to the accident, and what the causes were, so that we can address measures to prevent a recurrence."


Gliding Australia says Mr Turner (far right) was an experienced pilot who "loved soaring flight".(Supplied)

Police describe terrible tragedy

Police Inspector Brad Inskip said the two men were in two separate aircraft — a glider, flown by Mr Turner, and an ultralight believed to have been flown by a 77-year-old from Glenwood, north of Brisbane.

Inspector Inskip said the glider was known to have taken off from the nearby gliding club but it was unclear whether the second aircraft did the same.

"There's no doubt about it, this is a tragic incident," he said.

"It's a terrible scene, terrible incident, and terrible for the family and obviously those involved."


Queensland Police Inspector Brad Inskip says police are investigating whether the aircraft crashed in mid-air.(ABC News: Jessica Ross)

nspector Inskip said the deaths were going to hit the gliding community hard.

"The gliding clubs obviously are very close. This is a small regional gliding club. They all know each other," he said.

He asked anyone with information about the incident to come forward.

'We saw the two aircraft...'


John and Lyndal Kenman heard a loud bang and saw the two aircraft fall to the ground.(ABC News: Jessica Ross)

"You immediately know it's not good."

Mr McKinnie said he felt "intense sadness" when word of the deaths reached him in Canberra.

"It's sadness for the families and friends and club members involved," he said.

"It's a sense of deja-vu — unfortunately the sport has inherent risks and many of us know people who have lost their lives doing the things they loved.

"Our feelings are absolutely with family and friends within that aviation community."

He said due to the early stages of the investigation, it would be inappropriate to comment on the crash itself.


Gliding Australia safety manager Drew McKinnie says the tragedy will bring "intense sadness" for clubs, families, and friends.(Supplied: Australian Defence Force)

The Australian Transport Safety Bureau gathered information about the collision, before confirming it would not investigate.

"The ATSB does not investigate accidents and incidents involving most recreational, ultralight and sports aviation aircraft," ATSB chief commissioner Angus Mitchell said.

"The ATSB would only investigate accidents involving sport aviation aircraft that are not registered with the Civil Aviation Safety Authority, and non-powered glider aircraft, such as those involved in the Kybong accident, on an exception basis, as its resources permit, where conducting such an investigation has the potential to highlight wider safety issues.

"The ATSB empathises with the next of kin who have lost loved ones in this accident and are seeking answers as to how the accident occurred."

The Forensic Crash Unit is investigating the crash.

A report is being prepared for the coroner.


Authorities are investigating the crash at Kybong, near Gympie.(ABC News)

Hmm...(part in bold) turf war? - You bet!   

MTF...P2 

[Peetwo]

Dots-n-dashes missing on Popinjay's search 4 IP (QON for Senator Canavan) - 

Follow along the following timeline of discontinuity in the never ending ATSB search for (ICAO endorsed)  investigative probity - 

Via the ATSB 2016-17 Annual Report (page 134): 

In April 2017 the International Civil Aviation Organization (ICAO) conducted an on-site
audit of the ATSB’s compliance with ICAO’s standards, recomme nded practices
and guidance material for aircraft accident investigation. Australia sought the audit
from ICAO with ATSB Chief Commissioner Greg Hood stating, ‘This is an important
opportunity for the ATSB to demonstrate its accident investigation capabilities against
the benchmark set by ICAO. We know that we are doing well in a number of areas but
the results of an audit can give us new insights into how we conduct investigations,
with a view to enhancing our capacity to deliver outcomes for aviation safety’.

The audit covered core areas including:

> promulgation of aircraft accident investigation legislation
> establishment of an independent accident investigation authority
> allocation of sufficient financial resources
> qualifications and training of personnel
> availability of facilities and equipment
> establishment and implementation of investigation procedures
> the conduct of timely investigations and publication of findings.



Ref: https://www.atsb.gov.au/media/news-items...-from-thor

The ICAO auditor sent to Australia was Mr Thor Thormodsson. He has a background
as a commercial and instrument-rated pilot and as an accident investigator. He has
conducted ICAO audits for the past eight years.

Mr Thormodsson said the following in relation to his work as an ICAO auditor, ‘On
the whole, my job is highly rewarding. It keeps me in touch with the outside world.
ICAO perform an audit, then go back to the country and see significant differences due
to the audit fndings and safety recommendations’.

Australia is fortunate that it has a relatively mature safety oversight system and expects
that the audit will reect well on Australia’s conformance with ICAO’s requirements for
accident investigation. Where there are identified opportunities to improve, the ATSB
will be working to ensure positive change.

The results of the audit will be made available through ICAO’s online portal.

Then ffwd to this - ICAO ICVM Final Report summary:

1st this bit:

The ICVM team was composed of:

a) Mr. Nicolas Rallo, team leader, primary aviation legislation and specific operating regulations (LEG)/civil aviation organization (ORG)/ aircraft accident and incident investigation (AIG);

Then this:

4.2 In the case of Australia, the ICVM team visited the following organizations:
Airservices Australia (Air Navigation Services Provider National Operations Centre – Air
Traffic Flow Management, Aeronautical Information Services), Bureau of Meteorology
(Aeronautical Meteorological Services) and Australian Maritime Safety Authority
(Aeronautical and Maritime Search and Rescue Services) (ANS).

Hmm...funny there is no mention of Thor's (HVH endorsed) visit to the ATSB??

But then there is this (possible -  ) mention here of Thor's audit of Hoody:

3.1.3 A second USOAP audit (AIG area only) conducted in 2017 resulted in an overall EI of 85.05 per cent for the eight CEs of the State’s safety oversight system.

However the only outstanding finding (apparently) of Thor's audit was stated here in the ICAO ICVM audit report summary:

AIG:

Fully implement the ATSB’s action plan to ensure that all accident and incident investigation reports are completed within the established timelines.

Hmm...so was the 'action plan' developed from the findings of Thor's report? Who would know because we've never actually seen Thor's report, nor has there ever been made any further mention of Thor's audit ever since the publication of Hoody's 2016-17 AR??

Let's now ffwd to 14 March 2019 where the ANAO released their report into the ATSB to which these recommendations were issued:

Recommendation no.1

Paragraph 2.8

The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.2

Paragraph 2.18

The ATSB report on the efficiency with which it uses resources in undertaking investigations.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.3

Paragraph 3.5

The ATSB establish more realistic targets for investigation timeframes addressing both calendar and investigator (effort) days.

Australian Transport Safety Bureau response: Agreed.

Recommendation no.4

Paragraph 3.21

The ATSB continue to progress actions that it has recently commenced to benchmark its investigation performance against relevant international comparators and use the results to identify strategies to improve its performance.

Australian Transport Safety Bureau response: Agreed.

Now ffwd to the following interim report, which was issued over 7 months after the incident occurred...

Interrupted engine start and evacuation involving SAAB 340B, VH-ZRK Melbourne Airport, Victoria, on 5 April 2022

This interim report details factual information established in the investigation’s early evidence collection phase, and has been prepared to provide timely information to the industry and public. The report contains no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this interim report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

 
Hmm...the following is an extract from ICAO Annex 13:

Dispatch

7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available.

Next, despite stating this...

Safety action

Following the occurrence, Regional Express took the following safety action:

• A new hand signal was developed to indicate an interrupted engine start and was included in face-to-face and computer-based training content.
  
• A training package and guidance was provided to ground staff about dispatch procedures and hand signals.
  
• Guidance highlighting the correct marshalling signals was issued to all flight crew.
  
• Posters detailing ground signals were placed in ground crew high traffic areas.
  
• Operational manuals for both the flight crew and ground crew in relation to hand signals were reviewed and updated.
  

It would seem to me that the safety issues highlighted in the interim report have effectively been addressed internally by REX, however the ATSB goes onto say...

Further investigation

The investigation is continuing and will include review and examination of:

• flight crew failure management procedures
  
• crew communication and coordination
  
• flight crew, flight attendant and ground staff recurrent training
  
• on-board recordings. 
  

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

WTF - 

MTF...P2 

[Peetwo]

Dots-n-dashes missing on Popinjay's search 4 IP - Part II

Via Accidents Domestic:

Popinjay's bollocks excuse for not investigating Gympie midair?? - 

Via the Yaffa: 

We won't investigate Gympie Crash: ATSB

18 November 2022



ATSB Chief Commissioner Angus Mitchell told Australian Flying the decisions were in line with the ATSB's normal procedures.

“We understand the perceived inconsistency regarding the ATSB’s response to these occurrences, and I welcome this opportunity to clarify these decisions, which are in line with our Ministerial Statement of Expectations," he said.

“The propeller loss occurrence related to the manufacture, design and/or maintenance of the aircraft itself. As Australia is the state of design and state of manufacture for the Jabiru aircraft, and there are aircraft of the same type on the VH register, and operating overseas, the ATSB investigated the occurrence to determine if there were broader lessons for the aircraft type.

“In contrast, the Kybong mid-air collision was an operational event, involving an RA-Aus registered kit plane manufactured in the Czech Republic, and a VH-registered–but unpowered–glider, which was also not designed or manufactured in Australia.

"Neither of these aircraft therefore fall under the ATSB’s standard remit for investigation.

"The ATSB would only investigate accidents such the Kybong mid-air collision on an exception basis, as its resources permit, where conducting such an investigation has the potential to highlight wider safety issues."

UFB! - 

Hmm...so where in the SoE does it state anything like "Thou shalt not...investigate recreational aircraft fatal midair accidents...especially if the aircraft involved are a kit plane made in the Czech republic and a unpowered, foreign manafactured glider -   
  
All the SoE says is this:

"..(b) give priority to transport safety investigations that have the highest risk or potential to deliver the greatest public benefit through systemic improvements to transport safety;.."

The current SoE also says:

..I expect the ATSB to perform its functions consistent with Australia's international obligations where appropriate, including the requirements of the International Civil Aviation Organization.

I also expect the ATSB to implement any recommendations of the Australian National Audit Office and continue to work towards the timely finalisation of investigations to support continuous improvement in transport safety...

     

Okay...'cleared to backtrack'  - 1st in line with above, a quote from the 2013 Senate ATSB AAI Inquiry: 

3.17 The committee is aware that Annex 13 of the International Civil Aviation Organization's (ICAO) Chicago Convention, to which Australia is a signatory, places certain requirements on the ATSB and CASA.9 This means that ATSB reports should, in theory, comply with these requirements. 3.18 The annex sets out rules for the notification, investigation and reporting of an accident, who should conduct the accident investigation and how, which parties can be involved and their rights, as well as how results of the investigation should be reported. Accident investigations conducted by member states are required to:

• gather, record and analyse all available information on a particular accident or incident;
• issue safety recommendations where appropriate;
• determine the causes of the accident if possible; and
• produce a final report.

3.19 The investigation authority, in this instance the ATSB: …shall have independence in the conduct of the investigation and have unrestricted authority over its conduct, consistent with the provisions of this Annex.

3.20 The annex stipulates that final reports should be released as soon as possible in the interest of accident prevention, preferably within 12 months. If reports cannot be produced within 12 months, an interim report is to be released on each anniversary of the accident.

 

And ICAO obligations in regard to the issuing of preliminary and/or ADREP reports:

Dispatch

7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available.

Hmm...I wonder if the details of the Gympie midair fatal has been forwarded to ICAO? 

Next we ffwd again to 2017-18 after HVH took over and just prior to the release of the ANAO audit report and Thor's lost in the mail audit report - 1st via the Oz:

Air investigator ATSB vows to speed up complex probes


ATSB Chief Commissioner Greg Hood. Picture: Dylan Coker

By ANNABEL HEPWORTH
12:00AM JUNE 15, 2018

The nation’s air investigator says it expects to finish its complex investigations in a “timelier manner” after a program aimed at clearing a backlog of reports.

The latest figures show the Australian Transport Safety ­Bureau expects to publish 30 per cent of complex investigations within 12 months in 2017-18, against a target of 90 per cent.

ATSB chief commissioner Greg Hood said the ATSB was finishing complex investigations in an average of 16 months but was “actively working” to improve the timeliness.

The “Back on Track” program, aimed at clearing a backlog of reports, had been “productive”. Some 30 investigations that were behind time were now finished, while a further five to eight were expected to be done by the end of the financial year.

“Back on Track has required a diversion of significant resources away from our business as usual operations and therefore the percentage of complex investigation reports that have been completed remains around 30 per cent for this 2017-18,” Mr Hood said.

“I remain confident that when the Back on Track program is completed and these diverted resources return to business as usual operations, the ATSB will be positioned to complete its investigation reports in a timelier manner.” Mr Hood also pointed to other measures aimed at getting investigations completed more promptly, including moves to hire more transport safety investigators and be more selective in what it investigates.

While the headcount had gone down by about 25 per cent since the ATSB became an independent statutory body in July 2009, a recent budget boost had enabled an extra 17 transport safety investigators to be recruited.

“These investigators are currently being trained and a number have already had the opportunity to deploy to accident sites,” Mr Hood said.

“The process of establishing investigator competencies generally takes 18 months to complete, so we anticipate that we will begin to see the benefits of these additional resources in the next financial year results.”

As well, the ATSB would use its database to pinpoint cases with “the greatest potential for improving transport safety”.

The ATSB had started 120 investigations this financial year, compared with 162 investigations in 2016-17. “There are diminished safety benefits from investigating occurrences where there are obvious contributing factors, such as unauthorised low-level flying or flying visually into poor weather. Instead, we are refocusing our efforts on educating pilots on the dangers of high-risk activity. We are also placing emphasis on addressing accidents and incidents that recur through safety education.”

Then this weasel worded presentation by HVH to the 2017 ITSA (junket) conference in Tokyo:

Extracts :- 

...Like our colleagues from the Accident Investigation Board Norway (in reference to the organisational challenges presented through their abstract), the ATSB was enduring significant resourcing challenges which was seriously impeding its ability to meet prescribed deliverables and Key Performance Indicators, particularly in regards to the time taken to complete its safety investigation reports - on average the ATSB was completing about 30% of its complex investigation reports within the prescribed 12 months with some reports taking up to three years to finalise.

Since becoming an independent statutory authority in July 2009, the ATSB’s base appropriations had continued to reduce over successive financial years as the agency competed for funds with other important initiatives within the federal budgets. To manage these fiscal constraints, the ATSB had progressively reduced its staffing profile by an overall 25 per cent. In managing these reductions we facilitated a proportioned downsize across every business area within our organisational structure including corporate services...

...The Act states that the ATSB’s primary function is to improve transport safety, and our government’s “Statement of Expectations” requires us to continue to give priority to transport safety investigations that have the potential to deliver the best safety outcomes for the travelling public. When taking into account the known and projected financial and environmental challenges facing the agency, it was incumbent upon me to seek ways to maximise the efficiency and effectiveness of our operations. We could no longer afford (literally) to be complacent and continue with the mantra of “that’s the way we do things around here”...

...Our resources and deliverables were primarily geared towards completing occurrence investigations and I was concerned these resources were not being selectively allocated towards investigating those accidents and incidents that would have the greatest potential for safety learnings and enhancement...

...Effectively we needed to embark on a “step change”, where we would take our current resources (people and business operating systems) and realign them to achieve greater operational efficiencies and effectiveness. Along the way I needed to create an environment which empowers our people and maximises their opportunities for personal and professional growth.

Therefore I knew that a critical success factor for this evolution would be a paradigm shift in the way we think, moving from an accepted point of view to embracing a new one - noting the ATSB had not undergone any significant change in a number of years. Bringing to bear my knowledge of other multi-modal/multi-sectorial agencies and acting on my own experiential learnings, I decided to implement a significant transformation initiative known as the “Evolution” program. This program, in essence, was designed to enable better resource allocation and utilisation across the agency...

...Concurrently, we have progressed a sub-program known as “Back on Track” which by design has allowed us to accelerate the completion of approx. 50 investigations that had overrun duration and effort targets. This has also provided us the opportunity to review and carefully refine our investigation practices, procedures and workflows leading to a number of improvements including:

The introduction of an initial strategic planning session for each investigation which considers known information from site and initial inquires and decides on:

 Should the investigation be discontinued?
 Potential safety factors and issues?
 Key lines of further inquiry to substantiate or discount factors
 Predicted investment of effort required & agreed investigation Category
 Communications strategies (including Preliminary report, Web updates, discontinuation statement) 
 The introduction of periodic safety factor reviews (every 2-3 months) to consider information from investigative inquiry and analysis to decide on:

 Validated and discounted safety factors
 Validated, discounted and potential safety issues
 Safety action proposed and undertaken  Investigation profile ranking and risks
 Further lines of inquiry & assignment
 Re-categorisation (up or down)
 Communications strategy review.
 The inclusion of a final safety factor review which the Chief Commissioner attends - to consider the proposed findings and safety issues, and confirm:

 Validated safety factors
 Validated safety issues
 Safety action undertaken and any further proposed
 No further investigation required  Stakeholder risks & mitigation
 Communications strategy review (report, media engagement, industry, NoK)
 Executive approval workflow stages required.

Combined, these initiatives will enable us to improve the timeliness of our reports while maintain high standards of quality assuredness.

 
Then to the ANAO audit: Ref- https://www.aph.gov.au/Parliamentary_Bus...59%2F27991

Extract: 

Governance
3.10The ANAO acknowledged that the ATSB has been active in improving investigation efficiencies through improved governance structures and processes.15

3.11 In 2017, the ATSB initiated two programs aimed at increasing the efficiency of investigations: The Evolution Program and the Back on Track Program. The Evolution Program enables better resource allocation and utilisation to maximise the efficiency and effectiveness of operations by addressing the organisational structure, culture, efficiency, learning and development, talent management, succession planning and leadership of the ATSB.16

3.12 The Evolution Program also included the transformation of the agency to a multimodal, teams-based agency which aims to improve the effectiveness of the ATSB’s investigators. This was achieved by enabling investigators to investigate any type of accident,17 where previously they investigated one mode of transport only.

3.13 The Back on Track program, implemented in mid-2017, targeted the ongoing backlog of open investigations for completion. Significant resources have been allocated to this initiative to clear this backlog and meet newly framed KPIs. After the 40 investigations identified as a priority are finalised, diverted resources will be brought back in line to perform business as usual tasks.

Performance Measurement and Management

3.14 The ATSB has amended KPIs for investigation timelines. A KPI focusing on demand capacity has been introduced which considers the ATSB’s workload at a point in time and how much work can be taken on, realistically, against the resources on hand. The demand capacity KPI projects a decline from the current caseload of around 100 over the next three to four years. The ATSB explained:

That KPI recognised where we were at, which was a caseload of around 100 investigations, and what it's doing is projecting out to understand the resources we have available to get us down to a realistic case load. That is projecting out over the next three to four years, to dropping down to 50 or 60 complex cases on our books at any one time, and that’s being reviewed on a rolling monthly basis.18

3.15 The ATSB advised that work is underway to improve data collection and analysis that will help inform assessments of investigation efficiency.19 This will assist the ATSB with the development of more realistic and effective investigation timeframes.

3.16 Since the audit the ATSB has taken on 17 new transport safety investigators who will be trained, skilled and mentored to maturity within approximately three years. Further, investigator training will now be handled by RMIT University. This change releases resources within the ATSB previously utilised for training new staff. This sits well against the Chief Executive Officer’s description of the ATSB as a ‘doing organisation not a training organisation’20. Operations will slow down during this training and ‘getting up to speed phase’ but the efficiency metrics will improve once training has been completed.21

So that's the background, now to assess whether all that Hooded Canary self-serving gobbledy gook actually achieved any real positive reform; or was it just another bureaucratic 'make work' series of initiatives to justify the ATSB's existence?

MTF...P2