[Peetwo]

AOPA Oz live on ATSB's refusal to investigate Gympie midair??

Via YouTube: 

AOPA AUSTRALIA - LIVE - TONIGHT, 7PM
ATSB REFUSAL TO INVESTIGATE DOUBLE FATAL MID-AIR COLLISION

Join AOPA Australia CEO Benjamin Morgan and Director Clinton McKenzie as they discuss the recent ATSB refusal to investigate a double fatal mid-air collision accident in Queensland, examining the Transport Investigation Act.

TONIGHT'S PANELISTS

- Benjamin Morgan - CEO, AOPA Australia
- Clinton McKenzie - Director, AOPA Australia

POST A COMMENT OR QUESTION

AOPA Australia invites our members and supporters to post comments and questions during the LIVE broadcast, which we will do our best to address and respond to during the discussion.

MTF...P2 

[Peetwo]

Popinjay's bizarre 'no learnings' mantra continues on Gympie midair?? - 

Via the other Aunty:

ATSB criticised for refusing to investigate Gympie plane crash that killed two pilots

ABC Sunshine Coast / By Jessica Ross
Posted Sun 4 Dec 2022 at 10:19am


The planes came down on a dairy farm about 200 metres from one another.(ABC Sunshine Coast: Jessica Ross)

Aviation groups and the family and friends of the two pilots killed in a mid-air collision near Gympie fear they may never know what went wrong because the Australian Transport Safety Bureau (ATSB) is refusing to investigate the crash.

Key points:

• Two aviation groups representing the pilots killed say the ATSB should investigate
  
• The ATSB says it won't examine the crash because it is "unlikely to yield new safety learnings"
  
• The family of one of the pilots involved fear they will never have closure
  

Experienced pilots Christopher "Bob" Turner, 80, of Caboolture, and Barry Irvine, 77, of Glenwood, died on November 9.

Mr Turner was flying a glider and Mr Irvine was behind the controls of a small recreational plane.

The aircraft collided in the clear sky above a dairy farm at Kybong, a few kilometres away from the Gympie aerodrome.

Gliding Australia president Steve Pegler said the ATSB should "absolutely" be investigating.

"There's all these safety lessons that are still to be learned out of it," Mr Pegler said.


Gliding Australia president Steve Pegler says the pilots' families deserve a thorough investigation.(Supplied: Gliding Australia)

"We've got two people who have died and the ATSB has walked away from it … which is a real shame — it's a lost opportunity."

Recreational Aviation Australia (RAAus) has echoed the call.

Chief executive Matt Bouttell said the Transport Safety Investigation Act provided an "out" for the ATSB, because the accident involved sport aircraft.

"They've chosen not to … however, ultimately an independent review needs to be done," he said.

"This is about two aircraft in a very busy airspace, not far from a major airport … where this may have been two large, passenger-carrying aircraft."

The Queensland Police Service's Forensic Crash Unit is investigating, but a spokesperson said no comment could be made while the case was open.

Mr Pegler said he respected the police's efforts.

"But they're not subject matter experts when it comes to aviation," he said.

"We'd be quite happy to offer that assistance if they asked for that, but they haven't at this stage."


Barry Irvine is being remembered as an exceptional pilot and talented musician who lived life to the fullest.(Supplied)

Tragedy strikes twice

The lack of an investigation by the national authority has been a bitter blow for Mr Irvine's family.

Mr Irvine's brother Colin died in a hang-gliding accident in 1975.

Surviving brother Terry Irvine said Colin's accident was thoroughly investigated by the Civil Aviation Safety Authority at the time.

"There was no definite conclusion on the cause and that left us maybe with some questions unanswered, but at least there was an attempt to find answers," Mr Irvine said.


Terry Irvine says he loses sleep wondering about his brother (pictured) and his final moments.(Supplied)

He said while he supported the police investigation into Barry's accident, he feared it would not lead to changes that could prevent similar tragedies.

"I have problems going back to sleep because there are questions churning over in my mind," Mr Irvine said.

"The hard part is ... knowing that we will probably never find the answers in this situation.

"I don't want to be calling for any bans on recreational or light aircraft activities … but at least some sort of investigation … in the hope that the number of accidents is reduced, to stop other families from going through what my family and the other pilot's family are going through."


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

Caboolture Gliding Club president Garrett Russell flew with Mr Turner for years.

"He was one of the most experienced and most meticulous pilots that I had the pleasure of flying with, and a great instructor," Mr Russell said.

"People have died … an investigation would be very valuable for all pilots … to know what happened, because a mid-air collision is something that can happen to any aircraft.

"It's rare … but we want to make it even more rare."


Christopher Turner (left) is remembered as a "meticulous" pilot.(Supplied)

No new 'learnings'

ATSB chief commissioner Angus Mitchell said it was a "long-established government policy" to prioritise resources on investigations with the potential to deliver the greatest public benefit.

Mr Mitchell said mid-air collisions were rare and any ATSB investigation would be "unlikely to yield new safety learnings for the aviation industry".

He said there was "self-administration arrangements" for the recreational sector to undertake its own accident investigations.

"Where requested and as resourcing permits the ATSB may assist sport and recreation aviation organisations," Mr Mitchell said.

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


Mr Bouttell says there can be a perception of a lack of independence if his organisation investigates an incident involving a member.(Supplied)

Mr Bouttell said his group had conducted investigations in the past, but it should not have to.

"Enough is enough on the basis that we expose our people, our own employees and volunteers, to some pretty horrific scenes," he said.

"Furthermore, the expertise lies with our ATSB."

Courtesy AOPA Oz, via FB:

STATEMENT FROM ATSB CHIEF COMMISSIONER ANGUS MITCHELL

In accordance with long-established government policy, the ATSB is funded and directed to prioritise its resources on transport safety investigations that have the potential to deliver the greatest public benefit through systemic improvements to transport safety, and would only investigate accidents involving recreational aviation aircraft on an exception basis where a particular third-party risk is identified.

In the Kybong mid-air accident, both aircraft were operating in non-controlled airspace. Procedures for operating in non-controlled airspace are long established, mid-air collisions in uncontrolled airspace are rare, and any ATSB transport safety investigation would be unlikely to yield new safety learnings for the aviation industry.

The ATSB notes that the self-administration arrangements for the recreational aviation sector specifically provide for self-administration bodies to undertake accident investigation, and that the safety learnings from accidents in the sector are usually limited because the causal factors are generally well-understood. 

Where requested and as resourcing permits the ATSB may assist sport and recreation aviation organisations’ investigations through providing technical assistance, such as a metallurgical examination of aircraft components or data recovery.

Investigator representatives from recreational aviation organisations are also able to attend the ATSB’s transport safety investigator graduate certificate course, which is delivered jointly by the ATSB and RMIT University.

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

-- END

Comments in reply: 

Clinton McKenzie

I'm astonished by the suggestion that there's nothing more to learn. As I said in the AOPA broadcast, until you know what happened, you don't know whether there's anything to learn.

And I'll reiterate here something I've said above, so that the particular point can be debated:
Let's think about how best to keep RPT passengers safe, given that's the ATSB's priority (and funded out of the CRF rather than a new tax on airlines...). What do you think is the most likely cause of an RPT hull loss?

Currently, RPT aircraft operate in and out of aerodromes in G airspace. I think the most likely cause of an RPT hull loss is a collision with a 'light' aircraft in the vicinity of an aerodrome in G. If I were an RPT passenger, I'd be wanting the ATSB to be focussing on the risks arising from the way 'light' aircraft operate and, therefore, be looking very, very closely at all mid-air collisions in G.

And I've often said: If you want to keep aircraft operating in and out of e.g. Sydney safe, you better be making sure that student pilots operating in and out of Bankstown are competent (at least 'back in the day' when Bankstown was busy).

But that's just my opinion.

---

Lorraine MacGillivray
  · 31:08

Glider pilot, recreational pilot, nothing to see here folks I believe is the go. All pilots lives matter. If a person involved in an accident is a celebrity or it will gather media attention ATSB will probably investigate. Sad! Motor vehicle accident fatalities are all investigated doesn’t matter if you are a commercial driver or a private individual.

---

Paul Strike
  · 26:07

Why was the Mackay Jodel investigation ceased. There was a mammoth amount of learning from that event. All the wrong things were done by the deceased (RIP) and people need to know there are consequences for not complying with the "System" that is designed to keep us as safe as possible.

---

Shannon Baker
  · 46:56

It's almost a form of selective enforcement of the regulations.

---

Gary Weeks
  · 21:02

There should be just one regulator (CASA) and one accident investigation organisation (ATSB).
Picking and choosing the fatal aviation accidents to investigate when they are (under the TIA) bound to.

---

Randal McFarlane
  · 13:14

Outrageous behaviour on the part of the ATSB commissioner and government. Leaving the state police to attempt an investigation in most cases

Let’s look at the FAA and NTSB do and mirror this.

Finally CM's quote from the ICAO Annex 13 notified differences to Para 5.1: 

"..Australia may not institute an investigation
into ‘domestic’ accidents where the aircraft
concerned is on the Australian Register.
Decisions on whether a particular domestic
accident will be investigated will depend on
resources and the likely benefit to future
safety, particularly in the general aviation
sector..."

Para 5.1 reads:

5.1 The State of Occurrence shall institute an investigation into the circumstances of the accident and be responsible for the conduct of the investigation, but it may delegate the whole or any part of the conducting of such investigation to another State by mutual arrangement and consent. In any event the State of Occurrence shall use every means to facilitate the investigation.

Hmm...I wonder if the ATSB have reported the accident to ICAO?

MTF...P2 

[Peetwo]

Popinjay recommends TAWS for GA Aircraft; & still waiting for DFO final report??

From the Chief Commissioner who refuses to investigate a double fatal midair collision accident near Gympie - : 

ATSB urges fitment of terrain avoidance and warning systems to smaller passenger aircraft



Key points

• Aircraft was being flown 1,000 ft below the recommended descent profile, and had probably entered areas of significantly reduced visibility, including heavy rain;
  
• The pilot was probably experiencing a very high workload, and it is evident they did not effectively monitor the aircraft’s altitude and descent rate for an extended period;
  
• A TAWS (terrain avoidance and warning system) would have provided the pilot with both visual and aural alerts of the approaching terrain for an extended period.
  

A Cessna 404 with a pilot and four passengers on board was being flown 1,000 ft below the recommended descent profile before it collided with sand dunes about 6.4 km (3.5 NM) short of the runway at Lockhart River, an ATSB investigation report details.  

The twin piston-engined Cessna was operating a charter flight under the instrument flight rules from Cairns to Lockhart River on the morning of 11 March 2020. Consistent with the weather forecast, at Lockhart River there were areas of cloud and rain that significantly reduced visibility. Recorded data showed that the pilot commenced a go-around while conducting an area navigation (RNAV) GNSS instrument approach, using the aircraft’s instruments and two GPS units, to runway 30.

The pilot then commenced a second approach to land at Lockhart River, during which the aircraft probably entered areas of significantly reduced visibility, including heavy rain.

“The aircraft appeared to have been in controlled flight up until the time of the impact, and there was no evidence of any medical problems or incapacitation for the pilot, nor pre-existing mechanical problems with the aircraft or its systems,” said ATSB Chief Commissioner Angus Mitchell.

The pilot and passengers were fatally injured in the accident, and the aircraft was destroyed.
From the available evidence – the aircraft was not fitted with a cockpit voice recorder or a flight data recorder, but nor was it required to be – the ATSB could not conclusively determine the most likely scenario to explain the descent below the recommended profile on the second approach.

The ATSB considered three main scenarios as to why the aircraft was operated 1,000 ft below the recommended descent profile: that the pilot thought they were one segment further along the approach; that the pilot believed they were 1,000 ft higher than they actually were during most of the descent; and that the pilot intentionally descended below the recommended descent profile and segment minimum safe altitude in order to maximise the chances of becoming visual before reaching the missed approach point.

“Overall, mis-reading the altimeter by 1,000 ft appears to be the most likely scenario, although there was insufficient evidence to provide a definitive conclusion,” Mr Mitchell noted.
“Regardless, it is evident from the continued descent that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period, and that they were probably experiencing a very high workload.”

Mr Mitchell noted that conducting instrument approaches in poor visibility and hand flying an aircraft in single-pilot operations is particularly demanding.

“In addition to the normal high workload associated with a single-pilot hand flying an instrument approach in poor visibility, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.”

The accident aircraft was equipped with two Garmin GNS 430W GPS navigation and radio units, which have an advisory-only terrain awareness function capable of providing visual pop-up terrain alerts. However, it was unclear if the pilot had selected this function during the accident flight. While the operator did not provide procedures or guidance for its pilots on the function’s use, it was not common for operators of aircraft with such units to do so.

Mr Mitchell said the ATSB’s investigation highlighted the importance of a terrain avoidance and warning system (TAWS) in preventing controlled flight into terrain (CFIT) accidents, and urged operators of smaller aircraft conducting passenger operations to consider their fitment.

“Given the aircraft’s descent profile on the second approach, a TAWS would have provided the pilot with both visual and aural alerts of the approaching terrain for an extended period.”

There was no requirement for the accident aircraft to be fitted with a TAWS. As part of the long-planned introduction of new Civil Aviation Safety Regulations on 2 December 2021 (Parts 121 and 135), the Civil Aviation Safety Authority mandated the fitment of a TAWS to piston-engined aeroplanes used for air transport with a passenger seating capacity of 10 or more. However, even if the changes to the TAWS requirements had been introduced in Australia earlier, they probably would not have resulted in an aircraft such as that used during the accident flight being fitted with a TAWS.

“The ATSB urges all operators conducting air transport operations to evaluate the risk of CFIT in your operations and to actively seek to install TAWS in your aircraft to maximise the safety of your operations,” Mr Mitchell said.

“And if a TAWS is not currently viable, but your aircraft has a GPS/navigation unit that provides a terrain awareness function, fully understand the nature and limitations of this function and develop procedures and guidance for your pilots about its operation.

“Further, seek to fit your aircraft with a GPS/navigation system that provides vertical guidance on non-precision approaches; develop or review flight profiles for instrument approaches; develop or review your stabilised approach criteria to ensure it is suitable for instrument meteorological conditions; and review the content and frequency of your flight crew proficiency checks to ensure they provide sufficient opportunities to monitor the way instrument approaches are being conducted during line operations.”

Read the report: AO-2020-017 Controlled flight into terrain involving Cessna 404, VH-OZO, Lockhart River, Queensland, on 11 March 2020

Publication Date
15/12/2022

Hmm...POPINJAY TO THE RESCUE! - 

Next I go in search of an update on the Essendon DFO cover-up:

Aerodrome design changes and the Bulla Road Precinct development at Essendon Fields Airport, Melbourne, Victoria

Update published 1 August 2022[/i]

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

Hmm...so 2 weeks out from the end of the year, where the duck is the FR Mr Popinjay??   

MTF...P2 

[Peetwo]

Popinjay cries poor, while continuing with no 'new learnings' investigations??

Via the “For want of a nail the shoe was lost” thread:

Back to RRAT for DCVs; a Popinjay confession; and Harmonising the National transport safety regulatory system??

RECOMMENDATION 9.4 – IMPROVING SAFETY THROUGH NO-BLAME INVESTIGATION AND RESEARCH The Australian Government should:  provide a sufficient annual appropriation to enable the Australian Transport Safety Bureau (ATSB) to carry out its functions, both existing and as proposed in this inquiry  formalise the role of the ATSB in conducting investigations and research involving Domestic Commercial Vessels and rail  amend the Transport Safety Investigation Act 2003 to enable the ATSB to conduct research and investigate incidents involving heavy vehicles, and autonomous vehicle technologies  direct the ATSB to undertake a clearly defined, phased transition into the heavy vehicle role, including an initial period of data collection and research to identify any systemic issues and incident types with the potential to inform policy. The costs of the ATSB should not be subject to cost recovery from industry, but the States and Territories should support the Australian Government by providing a consistent contribution to its total costs, rather than on a case-by-case basis.

Which got me going back to this, recently updated, ATSB webpage: https://www.atsb.gov.au/about_atsb/inquiry-submissions

To which it can be discovered that the ATSB made submissions to the NTRR:

National Transport Regulatory Reform Inquiry draft report

National Transport Regulatory Reform Inquiry issues paper

Plus the Review of DCV safety legislation: 

 Independent Review of Domestic Commercial Vessel Safety Legislation and Costs and Charging Arrangements

Organisation conducting the inquiry

Independent reviewers, reporting to the Minister for Infrastructure, Transport, Regional Development and Local Government 

Purpose of the inquiry

The Australian Government has commissioned an independent review to consider whether Australia’s legal framework regulating the safety of domestic commercial vessels is fit for purpose. The review is also to consider whether this regulatory framework is being delivered efficiently and effectively, and to consider options for future cost recovery arrangements.

Date of the ATSB's submission

5 April 2022

Summary of the ATSB's submission

This submission is a response to the consultation aid, released in February 2022, prepared for phase 1 of the independent review. The ATSB’s submission outlines matters for the reviewers to consider in relation to expanding the ATSB’s role.

Key points in the ATSB's submission

• The ATSB does not have an agreed role in relation to DCVs.
  
• In general terms, ATSB investigations improve safety.
  
• The ATSB does not have resources to prepare a considered comment on whether expanding its remit to include DCVs would support substantially improved safety outcomes.
  
• Any recommended change to the ATSB’s role should be considered in the context of any other jurisdictional expansion.
  

Ref: https://www.atsb.gov.au/sites/default/fi...bureau.pdf

Which brings me (finally) to Popinjay's confession...  

From page 4 of the ATSB DCV submission:

3.1.4 The ATSB is not in a position to continue conducting DCV-only investigations or taking on a
new role in DCVs in future unless new resources are made available for this purpose.
The ATSB’s financial position is already under strain in relation to its current jurisdiction.
The majority of the ATSB’s investigations are into aviation occurrences. As an indication,
in 2020-21, 85 per cent of the investigations the ATSB initiated were into aviation accidents
and incidents.

3.1.5 However, even with that level of activity, the ATSB did not investigate enough accidents
and incidents to fully meet the international standards and recommended practices
for aircraft accident and incident investigation outlined in Annex 13 to the Convention
on International Civil Aviation. In the rail sector, the ATSB is critically underfunded
to conduct rail investigations across Australia. The Productivity Commission inquiry into
national transport regulatory reform noted some of the challenges of the current rail funding
arrangements for the ATSB and recommended the Australian Government provide sufficient
annual appropriation to enable to ATSB to carry out its existing functions2.

 

Yet today, with that in mind, we get this from the ATSB...

Large bird carcass found at Chinchilla aerial application aircraft accident site



Key points

• Air Tractor aircraft was conducting spraying operations typically about 2 metres above the ground;
  
• A large bird carcass, later identified as an Australian bustard, was found in the cockpit;
  
• Preliminary report contains no analysis or findings but details information from the investigation’s early evidence collection phase.
  

A large bird carcass was found in the cockpit of an Air Tractor aerial application aircraft which had collided with the ground during spraying operations on a property near Chinchilla, Queensland, a preliminary report from the ATSB’s on-going investigation details.

The preliminary report contains no analysis or findings but details information from the investigation’s early evidence collection phase, and notes that the Air Tractor AT-502B had been conducting spray runs on the morning of 19 September 2022.

Around 1200, the loader at the private airstrip about 24 NM (44 km) south-east of Chinchilla from where the Air Tractor had been operating attempted to call the pilot to ask whether they needed more fuel.

Concerned with having received no response, the loader phoned the operations manager, who in turn contacted nearby farmers to assist with locating the aircraft.

At about 1215, a local farmer found the aircraft in the paddock where the pilot had been spraying. The pilot was fatally injured and the aircraft was destroyed.

“An ATSB examination of the accident site found that the aircraft had impacted terrain with the fuselage in a near vertical attitude, with its propeller and engine buried in the soft earth, and the wreckage contained to a small area,” said ATSB Director Transport Safety Dr Stuart Godley.

Ground scars and damage to the left wing indicated that the wing struck the ground at about 30° to the horizontal, and examination of the propeller and engine indicated that the engine was delivering power at the time of the impact.

There was no post-impact fire.

“A large bird carcass was found in the cockpit and the bird’s wings were located about 300 m north of the wreckage, in-line with the aircraft’s track,” said Dr Godley.

Biological residue from the bird was found outside the right cockpit window.

“At the request of the ATSB, the Australian Centre for Wildlife Genomics at the Australian Museum analysed biological specimens of the bird, identifying them as being from an Ardeotis australis, commonly known as an Australian bustard or Plains turkey.”

The Australian bustard is a large bird, 80 to 120 cm in height, with an average weight for an adult of 4.5 kg, with males weighing up to 8 kg. They are capable of flying but are mostly ground dwelling.

“The aircraft operator advised that for the field where the accident occurred, they expected that it would be sprayed at a height of about 2 m (6 ft) above the ground, to be just above the weeds.”

Dr Godley noted that the investigation is continuing, and will include research into the nature of birdstrikes and similar occurrences.

“Bird strikes resulting in fatal aircraft accidents are very rare, however, the ATSB is currently investigating a separate accident where a wedge-tailed eagle bird carcass was located near the accident site of a Bell LongRanger helicopter, which experienced an in-flight break-up near Maroota, New South Wales on 9 July 2022.”

The continuing investigation into the Chinchilla accident will include further review and examination of electronic components recovered from the accident site, operational documentation and maintenance records.

A final report will be published at the conclusion of the investigation

“However, 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,” Dr Godley said.

Read the report AO-2020-043:Birdstrike and collision with terrain involving Air Tractor AT-502B, VH-KDR, 32 km east-north-east of Chinchilla Airport, Queensland, on 19 September 2022

Publication Date
16/12/2022

"..and will include research into the nature of birdstrikes and similar occurrences..."

You mean like this?? Australian aviation wildlife strike statistics 2008 – 2017

Godley justifies continuing because we now have 2 fatals involving birdstrikes in less than a year.  Yet we have two complex midair collisions killing 6 pob in 2 years and we have nothing to see here?? - FDS!   

MTF...P2 

[Peetwo]

Popinjay's search 4 IP a hazy mirage?? -  

Via Popinjay cover-up HQ:

ATSB recommends improving inspection requirements after failure of 737 flap inboard programming roller cartridge



Key points

• Pilot of Boeing 737 noticed aircraft tended to roll to right after take-off from Sydney;
  
• Post-flight inspection found several components in left outboard aft flap actuation system had failed;
  
• ATSB recommends improving inspection specifications to capture potential fatigue cracking in key parts of flap mechanism.
  

An Australian Transport Safety Bureau investigation found multiple occurrences involving fatigue cracks and failures on 737 wing flaps in a location not included in the detailed flap actuation system inspection.

The investigation stemmed from an incident involving a passenger flight from Queensland’s Gold Coast Airport to Sydney, NSW, operated on 27 April 2022 by a Virgin Australia 737-800, registered VH-YFZ.

“Immediately after take-off the pilot noticed the aircraft tended to roll to the right, and so trimmed the rudder to keep wings level,” ATSB Chief Commissioner Angus Mitchell said.

The aircraft no longer required trim when the flaps were retracted for cruise, but the issue returned when the flaps were extended for landing into Sydney.

“A walk-around inspection after the flight found the outboard aft flap on the left wing had not completely retracted, and a subsequent inspection found several components in the aft flap actuation system had failed,” Mr Mitchell said.

The ATSB determined that a pre-existing fatigue crack progressed through the aft flap’s inboard programming roller cartridge, resulting in component failure.

“The last general visual inspection had been carried out on VH-YFZ’s left outboard flap, according to Boeing’s specifications, in October 2020, and no defects were found,” Mr Mitchell said.

“While it could not be determined whether the fatigue crack was present at that inspection, 10 other instances of cracking and/or failure of the programming roller were reported to Boeing between 2017 and 2022, and at least six of these were old enough to have been inspected several times prior to failure.

“Significantly, the area in which the fatigue cracks developed was not included in the detailed inspection that Boeing specified for the flap actuation system.”

Boeing has advised the ATSB that it does not agree that this issue warrants safety action – noting that a review of prior failures showed that aeroplane-level effects were correctly mitigated by flight crews, and the affected aircraft landed without further incident.

“While the ATSB acknowledges that Boeing’s risk management program does not classify this as a safety issue, the ATSB believes the reduction in safety margins involving a passenger-carrying aeroplane, and the frequency of occurrence – particularly in the past five years – warrants safety improvement in the detection of fatigue cracking prior to failure,” Mr Mitchell said.

“A detailed inspection of the flap actuation system already exists, and while it includes the aft flap rollers, it does not include the cartridges that house them. Inclusion of the cartridges in the detailed inspection would provide the greatest opportunity for fatigue cracks to be identified prior to failure.”

Read the report: AO-2020-029: Flight control systems occurrence involving Boeing 737-800, VH-YFZ Gold Coast Airport, Queensland, on 27 April 2022

Publication Date 19/12/2022

First point to note is the typo on the AO (occurrence) number above in red?? Maybe in his haste for self-aggrandisement, plus to possibly put up a smokescreen on the now over 4 year Essendon DFO cover-up inquiry - see HERE - Popinjay forgot to proof read his own presser?? 

However, despite the apparent absence of a prelim report published within 30 days of the occurrence, 7 months and 3 weeks must be close to a record for the ATSB completion of an AAI (defined desktop) investigation??  Probably because large sections of the brief final report are just a copy and paste from VA's internal SMS investigation and Boeing's DIP submission.

On DIP submissions I note that of the DIPs listed only Boeing and VA felt the need to make submissions -   

A draft of this report was provided to the following directly involved parties:

• the flight crew
  
• Virgin Australia Airways
  
• The Boeing Company
  
• the Civil Aviation Safety Authority
  
• the United States National Transportation Safety Board.
  

Submissions were received from:

• Virgin Australia Airways
  
• The Boeing Company.
  

The submissions were reviewed and, where considered appropriate, the text of the report was amended accordingly.

       
Which brings me to Popinjay's identified Safety Issue:

“While the ATSB acknowledges that Boeing’s risk management program does not classify this as a safety issue, the ATSB believes the reduction in safety margins involving a passenger-carrying aeroplane, and the frequency of occurrence – particularly in the past five years – warrants safety improvement in the detection of fatigue cracking prior to failure,” Mr Mitchell said.

Which just goes to show that Popinjay has examined the brief and taken note of the ATSB published 'safety issue':

AO-2022-029-SI-01

Response by The Boeing Company

On 15 November 2022, The Boeing Company provided the following response:

Boeing does not concur that this event represents a safety issue, when analyzed within our FAA‑approved risk management program. A review of prior failures shows that airplane-level effects were correctly mitigated by flight crews and the affected aircraft landed without further incident. Boeing’s review indicates that the event does not represent a significant reduction in airplane safety margins, and that the current inspection program is adequate.

ATSB comment in response

The ATSB acknowledges that, based on consideration of the consequence of the component failure, Boeing’s risk management program does not classify this as a safety issue. However, the ATSB also believes that the reduction in safety margins involving a passenger‑carrying aeroplane and the frequency of occurrence—particularly in the past 5 years— warrants safety improvement in the detection of fatigue cracking prior to failure.

The ATSB also notes that a detailed inspection of the flap actuation system already exists, and while it includes the aft flap rollers, it does not include the cartridges that house them. Inclusion of the cartridges in the detailed inspection would provide the greatest opportunity for fatigue cracks to be identified prior to failure.

Hmm...love to have been a fly on the wall in the halls of Boeing, the FAA and the NTSB when Popinjay issued this Safety Recommendation to Boeing...   

Action description

The Australian Transport Safety Bureau recommends that The Boeing Company takes safety action to increase the detection of fatigue cracks in the roller cartridges of 737‑800 aircraft prior to failure.

 

MTF...P2 

[Peetwo]

Popinjay flips the bird (again) at RAAus Pilot fatal -   

Via the other Aunty:

Pilot in fatal Nullarbor plane crash was 43-year-old Perth father-of-two Michael Hebbard

ABC Goldfields / By Jarrod Lucas
Posted Yesterday at 3:08pm


Michael Hebbard was the only person on board the light plane which crashed on the Nullarbor shortly after take off.  (Supplied: gofundme.com)

The pilot in last Friday's fatal plane crash on the Nullarbor has been identified as 43-year-old Perth father-of-two Michael Hebbard, described as a "loving partner" and "doting dad". 

Key points:

• Michael Hebbard, 43, of Perth, was killed in a light plane crash on the Nullarbor on December 16
  
• The crash occurred shortly after take-off from the remote Caiguna airstrip and was reported about 9:30am
  
• WA Police will prepare a report for the Coroner
  

• 
  

Michael Hebbard was a father of two young children.  (Supplied: gofundme.com)

According to his social media accounts, he served 10 years in the Royal Australian Navy and studied for a Master of Business Administration (MBA) at Curtin University.

"Mike was one of the most genuine, down-to-earth guys you were ever likely to meet and I wanted to do something to try and give something back to his partner Kristen and two young kids Finn and Stella at this terribly difficult time for them," Linton Allen posted on gofundme.com.

Cause of crash still undetermined

WA Police completed an initial investigation at the remote site over the weekend and the cause of the crash was yet to be determined.

Police said the plane crashed about 500 metres from the Caiguna Roadhouse, just off Eyre Highway, after taking off from the local airstrip.

He was making a stopover from Esperance and was believed to be transporting the aircraft to Queensland.


Online tributes described Michael Hebbard as a "doting dad".  (Supplied: gofundme.com)

Esperance Detectives took on the case after the Australian Transport Safety Bureau (ATSB) declined to investigate, saying it typically did not investigate recreational aircraft accidents.

Recreational Aviation Australia (RAA) criticised the move, saying it wrote to the Minister for Transport Catherine King in November raising concerns about the ATSB's inability to conduct investigations due to limited funding.

"We have seen at least five fatal accidents in the past 12 months and many in the years prior where the ATSB has chosen to not investigate," RAA chief executive Matt Bouttell wrote in the letter.

"This equates to a significant cost to the Australian people through awaiting State Coroners to arrive at findings that often result in diminished safety outcomes due to a lack of subject matter expertise during the investigation and evidence-gathering phase.

"Moreover, Australian families are effectively forbidden from obtaining closure due to those deficient outcomes."

Mr Boutell told the ABC that RAA has provided police with technical support in the past, but it has no legislative powers to conduct fatal accident investigations.

"We have previously provided police with on-site support at accidents, including performing analysis around the circumstances of the accident however, in recent times it's become clear that due to the lack of legislative protections, we cannot keep 'propping up' the ATSB by doing so," he said.

"We have therefore said enough is enough, and that the Government should fund the ATSB for the purpose it is established for." 
[/size]

Some comments in reply, via AOPA Oz Facebook page:

Dennis Hill

Under the Chicago Convention, all aircraft accidents are meant to be investigated. The problem is the ATSB just don't seem to have the budget to do so.

---

Gregg Bisset

Really sad. Lack of investigation ATSB should mean the end of RAAUS and CASA arrangements to increase weights as this could lead to a significant number of accidents not investigated and could in time have an impact on insurers. Michael's family deserve closure.

---

Ian Mooney

Yet they are able to investigate a Cessna 182 GA accident west of Bris. Why is 1 worthy of investigation while another is not?

---

Shannon Baker

Time to FOI ATSB finances and where the money goes. Oh boy imagine that can of worms.

Author

Aircraft Owners and Pilots Association Australia

Shannon Baker exactly. I am already speaking with Senators with respect to having this issue raised during the RRAT Hearings.

MTF...P2 

[Peetwo]

Clinton McKenzie Addendum

Ref:

Popinjay flips the bird (again) at RAAus Pilot fatal -   

Via the other Aunty:

Pilot in fatal Nullarbor plane crash was 43-year-old Perth father-of-two Michael Hebbard

ABC Goldfields / By Jarrod Lucas
Posted Yesterday at 3:08pm


Michael Hebbard was the only person on board the light plane which crashed on the Nullarbor shortly after take off.  (Supplied: gofundme.com)

The pilot in last Friday's fatal plane crash on the Nullarbor has been identified as 43-year-old Perth father-of-two Michael Hebbard, described as a "loving partner" and "doting dad". 

Key points:

• Michael Hebbard, 43, of Perth, was killed in a light plane crash on the Nullarbor on December 16
  
• The crash occurred shortly after take-off from the remote Caiguna airstrip and was reported about 9:30am
  
• WA Police will prepare a report for the Coroner
  

Some comments in reply, via AOPA Oz Facebook page:

Dennis Hill

Under the Chicago Convention, all aircraft accidents are meant to be investigated. The problem is the ATSB just don't seem to have the budget to do so.

---

Gregg Bisset

Really sad. Lack of investigation ATSB should mean the end of RAAUS and CASA arrangements to increase weights as this could lead to a significant number of accidents not investigated and could in time have an impact on insurers. Michael's family deserve closure.

---

Ian Mooney

Yet they are able to investigate a Cessna 182 GA accident west of Bris. Why is 1 worthy of investigation while another is not?

---

Shannon Baker

Time to FOI ATSB finances and where the money goes. Oh boy imagine that can of worms.

Author

Aircraft Owners and Pilots Association Australia

Shannon Baker exactly. I am already speaking with Senators with respect to having this issue raised during the RRAT Hearings.

Via the AOPA OZ Facebook:

Clinton McKenzie

There are nuances to the answer to the question as to what accidents/incidents ATSB has power to investigate in law. That’s a different question to the one as to what accidents/incidents ATSB chooses to investigate or not. The latter are necessarily a subset of the former.

Complex issues affect the ATSB’s jurisdiction to investigate an RAAus aircraft accident. They’re not VH-registered - and that’s one of the links to the ICAO convention obligation on Australia (from which obligation Australia has already filed a difference to the effect that Australia can choose not to investigate some accidents, anyway). RAAus aircraft are often owned by individuals (rather than constitutional corporations) often engaged in purely intra-state flights and usually engaged in purely private flights, all of which issues are relevant to the scope of ATSB’s jurisdiction.

Here’s what s 11 of the TSI Act says on this:

“11 Constitutional limitations on powers and functions

Aircraft
(1) The powers in this Act, so far as they relate to aircraft and air navigation, can only be exercised in relation to:
(a) air navigation conducted in the course of trade or commerce with other countries or among the States; or
(b) air navigation:
(i) outside Australia; or
(ii) within a Territory, or to or from a Territory; or
(iii) within a Commonwealth place, or to or from a Commonwealth place; or
(iv) on aircraft owned or operated by a constitutional corporation or Commonwealth entity; or
(v) in respect of which a State referral of power is in operation; or
(vi) in relation to any other matter with respect to which the Parliament has power to make laws; or
© giving effect to an international agreement; or
(d) matters of international concern.”

The mid-air at Gympie involved at least one VH-registered aircraft.

The 182 accident west of Brisbane was a commercial operation involving pax. The aircraft was Vh-registered and owned/operated by a constitutional corporation.

MTF...P2 

[Wombat]

The ATSB, by refusing to investigate fatal RAA accidents and apparently only allocating enough time for cursory reports on VH registered aircraft accidents has just demonstrated total incompetence at the management level. 

These are the published criteria for investigations from the ATSB website:

Level of investigative response 
Back to top

The level of investigative response is determined by resource availability and factors such as those detailed below. These factors (expressed in no particular order) may vary in the degree to which they influence ATSB decisions to investigate and respond. Factors include:  


the anticipated safety value of an investigation, including the likelihood of furthering the understanding of the scope and impact of any safety system failures  

the likelihood of safety action arising from the investigation, particularly of national or global significance  

the existence and extent of fatalities/serious injuries and/or structural damage to transport vehicles or other infrastructure  

the unique value an ATSB investigation will provide over any other investigation by industry, regulators or police  

the obligations or recommendations under international conventions and codes  

the nature and extent of public interest – in particular, the potential impact on public confidence in the safety of the transport system  

the existence of supporting evidence, or requirements, to conduct a special investigation based on trends  

the relevance to identified and targeted safety programs  

the extent of resources available, and projected to be available, in the event of conflicting priorities  

the risks associated with not investigating – including consideration of whether, in the absence of an ATSB investigation, a credible safety investigation by another party is likely  

the timeliness of notification  

the training benefit for ATSB investigators.  

Question: How can you assess the safety value of an investigation without doing a thorough investigation?

Answer: You cannot.

Furthermore, if you allocate resources on the basis of what you expect to find (eg pilot error when Old Farmer Brown stuffs his C172 into the dirt) then guess what? Your investigator will find exactly what you expected. This is known as justifying your conclusion, or putting cart before horse.

No. We don't need a 200 page report of every accident, merely that each and every fatal, whatever the registration, is pursued with an open mind until the cause and safety message is discovered. To do otherwise is guaranteed to result in missing emerging safety issues.

To put that another way, its insignificant if light aircraft occasionally demonstrate insufficient situational awareness at a certain airport....... .....until one situationally challenged RAA gent blunders in front of an Emirates A 380 on final.

[Peetwo]

Popinjay (ironically) to conduct AE investigation analysing GPS data?? -   

Via Popinjay cover-up HQ: https://www.atsb.gov.au/publications/inv...e-2022-005

Summary

On 9 November 2022, a Grob-Burkhaart Astir CS glider, registration VH-WVI, and a Kappa KP-2U Sova ultralight, registration 24-4311, collided mid-air, 2 km south of Gympie, Queensland.

The pilots of both aircraft received fatal injuries and both aircraft were destroyed. Recreational Aviation Australia has requested technical assistance from the ATSB to assist in its investigation.

The ATSB has been requested to download and recover flight data from the GPS. To facilitate this assistance, the ATSB has initiated an external investigation under the provisions of the Transport Safety Investigation Act 2003.

Any enquiries relating to the accident investigation should be directed to RAAus at: www.raa.asn.au

Some comments in reply, via the UP:

Squawk7700

Ops normal, nothing to see here, they have been doing that since GPS was invented as they are the only ones that have the required in-house skills with forensic oversight.

---

Lead Balloon

Any thoughts on how the GPS data, if accessible, will help? It will probably confirm that the aircraft tracked so as to end up at the same location, laterally and vertically, at the same time. I suppose the tracks and altitudes of the aircraft could be of some further assistance?

---

gerry111

Not a great start by the ATSB at least with the Aircraft Details: Since when was a GROB Astir CS an Amateur Built Aircraft?

---

Lead Balloon

Good point, GIII.

---

Clinton McKenzie

What worries most is that ATSB seems to believe that a collision between 2 ‘light’ aircraft (to use a neutral term) in G has no potential implications for its priority of systemic improvements to transport safety.

Ask any crew of an RPT aircraft operating in and out of an aerodrome in G what they consider to be their single biggest risk. Answer: The ‘light’ aircraft in the vicinity.

In a previous life I used to say that one of the ways in which we kept aircraft operating in and out of YSSY safe was to monitor, and secure compliance with the competence standards of, the student pilots operating in and out of YSBK. The same logic applies to every other RPT airport with adjacent ‘light’ aircraft aerodromes.

The safety of RPT aircraft depends, fundamentally, on the competence of the pilots of the ‘light’ aircraft with whom the RPT aircraft are sharing airspace. Are those pilots:

- monitoring the correct frequency (assuming the aircraft’s radio is serviceable)?

- making accurate and timely broadcasts of location, altitude, track and ETA on the correct frequency?

- keeping a proper lookout (assuming they have their glasses on)?

Almost every time I go flying, I see and hear evidence that the answer is often ‘no’. If I had a dime for the number of times I’ve heard a CTAF call on Area, I’d own a PC12. A while ago, I had a radio failure and had to join an active circuit without being able to make any broadcasts. I then managed to stuff up the first approach, so did a go-around and landed after a second circuit. This is with another aircraft in the same circuit with me. After that aircraft landed I walked over to explain to the pilot why he hadn’t heard from me. He said he’d never seen me! I’ve helped a pilot operate a fuel bowser because he couldn’t read the keypad…

And to anticipate one potential argument: RPT aircraft might be much bigger than your average ‘light’ aircraft and, therefore, easier to see in theory, but my first hand experience and observations are that the RPT aircraft are generally moving about 3 times faster than the average ‘light’ aircraft and can be hard to spot as a matter of practicality.

If ATSB’s view is that the competence standards of ‘light’ aircraft pilots create risks only to themselves and other ‘light’ aircraft pilots, I reckon the ATSB is wrong. Those pilots share airspace with RPT aircraft, or are supposed to confine themselves to airspace outside airspace in which RPT aircraft are operating. Any systemic incompetence in the ‘light’ aircraft pilot population creates risks to RPT. Either or both of the aircraft involved in the recent tragedy near Gympie could just as easily have been flying in the vicinity of Mildura, or Ballina or…

I stress that I’m not saying that either or both of the pilots of the aircraft involved in the tragedy were incompetent or that their training and ‘checking’ environment is systemically flawed. But something went wrong. I don’t know what or why. But nor does ATSB and ATSB is clearly not inclined to try to find out.

And TIBA and TRAs? Meh.

If the public on board RPT aircraft understood what's going on...

MTF...P2 

[P7_TOM]

We ancient Pelicans have one luxury – we may grumble, groan and bang on about the 'modern' world and no one pays us much attention. I remember, quite clearly working alongside my Grandpa and his son; both bemoaning and damning the 'new stuff' and attitudes. I can even remember some fairly 'lively' (perhaps robust even) discussions with my old man; and to this day, I occasionally collide head on with my own brood. Two points of view – both worthy of consideration; sensible discussion and of value to both. Occasionally, without resort to fisticuffs, two strongly held opinions merge into resolutions – those which pass the pub test.

For example; Christmas day, late in the afternoon, I ventured into the stable; an Ale was put on the bar and (eventually) the grass roots question was raised. “why did Dick do away with flight service?” Good one I thought; we both have operated when the FSU existed along with 'full reporting'; two minutes was the tolerance or an amendment. Away from 'city traffic' you would know, with absolute certainty, that the F27 was due at Jam Tin @07;36, FL 150 estimating 'Toast' @ 18:03 for an instrument approach. You, in turn advised your estimate and cruise level – everyone on the unit frequency knew what was going on; and those were 'busy' times. The Baron at 8000' was due at Jam Tin 0759; the C310 coming from the North was holding an ETA of 08:12 – the flight school PA28 was in the circuit and would hold 10 South of circuit until the F27 was settled in.

Now, unless you are operating IFR – and even then only sometimes do you get this level of information. I have dragged out some of the old style, handwritten 'approved' flight plans and, on the neatly folded 'flip' side I can see this sort of data clearly noted, a history if you will of aircraft operating in the same piece of the atmosphere as I was. Reasonably neat (not many serviceable auto pilots in those days) but, unless anyone did anything silly, outside of controlled airspace, we all seemed to manage quite well. I would dearly love a beer in the bank for every time I extended a downwind leg, or, held overhead, or, really shortened an approach to accommodate and avoid 'conflict' and been offered the same professional courtesy in return.

The thing which 'bothered' us both was my very true tale. Once upon a time, many (so many) moons ago I was to go to a port in central Qld, pick up a King Air 100 and deliver it to a new base; easy as – the owner rang; “I've a mate flying up to (port) tomorrow, and he'll give you a lift “ - “OK” says I, never gave it another thought, This was in the days when Garmin 100 was a mystery to most of us and the regulations were in flux (again). Anyway, off we toddled from a Secondary airport; the calls made were standard – until – it was announced that we were a 'local' area flight. Once clear of the zone; and for three and half long hours; was the radio not used – not once. A frequency change was made at some point, but, until we were within 10 miles of the circuit was any form of broadcast made. Not a soul in this world knew where we were; what height we held; what track and what time we'd be approaching an airfield or even that we existed. Tired, concerned and cramped I decided that it would be a waste to say anything – to anyone; it was probably quite legal anyway – and it still is to this day , far as I can tell for no plan VFR.  (N.B. - one heading - direct to - non quadrantal omitted from notes -'K').

The advent of GPS has been a boon to operations; no doubt about it; great tool. As one who has conducted (into the thousands) ADF and VOR approaches, the benefits are brilliant. But, IMO there is a downside; particularly to VFR cross country operations; 'Loss of situational awareness' is an 'inaccurate' definition; but it is now all to easy to click on the Auto pilot, select Nav and sit back and do the crossword, with a timer set, to remind you to change tanks. “Loss of contact' may be a better way to express it; modern gear has taken the 'labour' out of navigating, the careful attention to 'track' and the information provided to the pilot from 'outside' the aircraft. Big jets on long haul have long ago dispensed of this labour, but if anyone thinks for a minute, that those crews are not 'paying attention' and simply monitoring the 'automatics' – they are dreaming.

I have now wandered far from my intended track – it was to Gympie in Qld I was headed. I know the 'gliders' are punctilious in their notifications of operations; it is reasonable to assume these were in NOTAMS and available pre flight; we know that the airfield is clearly marked as having gliding operations, we also know that a quick phone call or radio call would have provided advice of glider traffic operations, where the best thermals were and how many craft they had airborne now and in the near future. What we don't know is how much information, warning and alerting the power aircraft pilot not only had, but gave. We also don't know if there was a brain fart; was this a spur of the moment thing, to try and find a glider and watch it work, take pictures?. The ATSB have grudgingly deigned to review the GPS data – WTF for? It will only show that the two aircraft tracked toward each other and collided. What we need to know is WHY and what part of the system failed; then we need that failure eradicated. That is the basic function of the ATSB – define the how and the why and the best course of preventing a repeat.

Sorry folks, 'K's' good Ale tends to aide and abet rambling. Best wishes to all for the new year...(They don't let me out very often)....

[Kharon]

Well; We don't know!

P7 - “I have now wandered far from my intended track – it was to Gympie in Qld I was headed. I know the 'gliders' are punctilious in their notifications of operations; it is reasonable to assume these were in NOTAMS and available pre flight; we know that the airfield is clearly marked as having gliding operations, we also know that a quick phone call or radio call would have provided advice of glider traffic operations, where the best thermals were and how many craft they had airborne now and in the near future. What we don't know is how much information, warning and alerting the power aircraft pilot not only had, but gave. We also don't know if there was a brain fart; was this a spur of the moment thing, to try and find a glider and watch it work, take pictures?. The ATSB have grudgingly deigned to review the GPS data – WTF for? It will only show that the two aircraft tracked toward each other and collided. What we need to know is WHY and what part of the system failed; then we need that failure eradicated. That is the basic function of the ATSB – define the how and the why and the best course of preventing a repeat.”

And, neither will the Coroner.

In fact, no one, bar the two dead pilots knows the why and how of the Gympie mid-air. But, eventually a Coroner will need to 'examine' the event and make some form of ruling which, in turn, will trigger the insurers response. To arrive at any sort of rational conclusion, the Coroner must rely, in one form or another, on 'expert' advice from the investigating agency. With aviation events, this is, almost without exception, the ATSB report. Now, each 'jurisdiction' (bar the Commonwealth) has its own coronial legislation, with subtle differences. But, no matter the nuances, they must rely on 'subject matter' expert testimony. Here is where the difficulties of the ATSB 'can't be bothered' response to the Gympie mid-air creates difficulties for not only the Coroner, but for all involved. Quite apart from it being reprehensible behaviour (and it is) from an expensive tax payer funded 'autonomy'. ATSB is in place and funded solely to present and provide independent, expert analysis and probable cause: additional funding available – 'on request' no questions asked. The outright refusal, on very (very) shaky grounds, to not  'investigate' the Gympie mid air fatal has far reaching consequences. Not only to overall aviation safety, but for the legal proceeding which will follow behind the Coroners rulings. 

I can almost hear the howls of derision from the legal eagles; but in lay terms, the ATSB is creating a legal minefield, which can only lead to long, drawn out, expensive legal action further down the 'event aftermath' road. In a nutshell (with apologises to the eagles) it goes something like this. The Coroners findings involves two elements, the 'cause' of death and the 'manner' of death.

So, Charlie is carrying a couple of bags of cement along a scaffold gangway – three stories up. He is last seen falling off the gangway, lands and is pronounced dead at the scene. The 'cause' of death would be identified as injuries sustained at the end of the fall. But the 'manner' of death would be 'how' that 'fall' came about. A moments thought will reveal not only the implications and liabilities, but the scramble to avoid legal action following the investigation. The builder will need to show the compliance with 'code' for scaffold, as will the scaffold company which assembled it, as will the site manager, Charlie's boss, etc. all roped in to the liability hunt; all hanging on for the Coroner's ruling on 'the manner' of death, not the cause. Is the Coroner an expert in any related field to this event? Nah and even if – then, probably, a change of Coroner would be required. Ergo - Independent investigation is an essential element; by independent experts in the field, with substantive protection under the law...

You can see how the 'liability' chain exists; the builder must provide a scaffold – was it there – Yes. Did the builder erect the scaffold – No, contracted out to an 'expert' certified company; did they install it correctly? The 'eagles' would have a field day with that – beginning with was the Scaff contractor a mate and job done at a rate? Were the riggers used qualified and supervised? Was the safety inspection done – who by? You see where this all leads – the Coroner can only make a 'safe' (read sound) decision based against a completely independent, no skin in the game – expert. Meanwhile, poor old Charlie's widow is wondering if the insurance will come through and praying Charlie didn't have a beer at lunch time and gets all the blame – 'drunk and in charge of a pair of boots' M'lud.

There must be unbiased, independent and honesty presented in Coroner's reports, no frills or, 'spin', or 'bias', or agenda (see Tasmanian fatal) -  provided to the Coroner and, by extension, to the insurance legal sharks. ATSB has that job; they have no financial restrictions attached when it comes to accident investigations; they have rock solid protection under the TSI Act; all they are lacking is some independence (see MoU) expertise (see reports) and integrity in the management department – been shy of that the last few years – and it shows.

Toot – toot...

[Peetwo]

Gold Coast chopper midair - Popinjay to the rescue (again.. )

Via Channel 9 News this AM - :

Popinjay is all over the news this AM flapping his gums doing a job that surely the IIC; or his professional media boffin; or even his Aviation Commissioner Manning would be better qualified to do...??     

Here is the initial media release (put out yesterday) from Popinjay:

 

Gold Coast helicopter mid-air collision

The following statement can be attributed to ATSB Chief Commissioner Angus Mitchell 
 
“The Australian Transport Safety Bureau (ATSB) has commenced a transport safety investigation into the fatal mid-air collision involving two helicopters near Seaworld on the Gold Coast, Queensland on Monday afternoon. 

“Transport safety investigators with experience in helicopter operations, maintenance and survivability engineering are deploying from the ATSB’s Brisbane and Canberra offices and are expected to begin arriving at the accident site from Monday afternoon.    

“During the evidence gathering phase of the investigation, ATSB investigators will examine the wreckage and map the accident site. Investigators will also recover any relevant components for further examination at the ATSB’s technical facilities in Canberra, gather any available recorded data for analysis, and interview witnesses and other involved parties.  

“The ATSB asks anyone who may have seen the collision, or who witnessed the helicopters in any phase of their flights, or who may have footage of any kind, to make contact via witness@atsb.gov.au at their earliest opportunity. 

“The ATSB anticipates publishing a preliminary report detailing basic information gathered during the investigation’s evidence collection phase in approximately 6-8 weeks.  

“A final report will be published at the conclusion of the investigation, however, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.” 

// Ends  

NOTE: The ATSB will be engaging with on-site media in the morning (Tuesday 3 January). Further details on the location of media activity will be distributed directly to media outlets/COS as soon as practical.  

Date
02/01/2023

Note the subtle differences between that and the one for the Appin Glasair fatal accident:

Popinjay to the rescue: Part II 

In search of further details of the NT and Appin fatal crashes, I note that as yet there has been no accident occurrence (AO-****-***) numbers issued for both these investigations: Refer - https://www.atsb.gov.au/aviation-investigation-reports.

To be fair this is probably because most of the office staff normally responsible for inputting these notifications are on Xmas/New Year leave.  

However Popinjay (again to the rescue) did issue two media releases on the 26th with some limited details about both these tragic accidents:    

Appin NSW aircraft accident

Released: 26 December 2022

The following statement can be attributed to ATSB Chief Commissioner Angus Mitchell:

“The Australian Transport Safety Bureau (ATSB) has commenced an investigation into a collision with terrain involving a foreign registered Glasair Super II aircraft near Appin, NSW which occurred shortly before 3.00pm on Monday.

“The aircraft came down in bushland in the vicinity of Appin Road, where on-site emergency services confirmed the two occupants on board were deceased.

"A team of transport safety investigators from the ATSB's Canberra and Brisbane offices are deploying to the accident site to commence the on-site phase of the investigation.

"The initial ATSB safety investigation will include an examination of the wreckage, assessment of aircraft and pilot records, weather information and any available recorded data.

"The ATSB’s evidence collection will define the size and scope of the investigation and determine the expected timeframe for the completion of a final report.

“The ATSB asks anyone who may have seen the aircraft in any phase of its flight, or who may have footage of any kind, to please make contact via our website - www.atsb.gov.au/witness

"A report will be published at the completion of the investigation. However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties."

// Ends

NOTE: The ATSB will not be providing any further statements in relation to this accident until the release of the preliminary report in about 6 - 8 weeks time.

Note also that the promised release of the prelim report is still 6 - 8 weeks, even though this is in contravention of recognised ICAO Annex 13 standards (Chapter 7 Para 7.4)...

MTF...P2 

[Peetwo]

ATSB v NTSB: CHALK and CHEESE?? - 

After being bombarded all day with the embarrassing, puerile Popinjay performance (at not only that press conference but with exclusive news grabs/interviews to every news channel that was onsite -    ) I got to thinking about doing a comparison to the high profile Kobe Bryant chopper accident investigation conducted by the NTSB.

If you can bare to watch it, here is the Popinjay performance in full (via the ABC):     

Note that Popinjay completely wings it and doesn't seem to be backed by any of HIS investigators let alone the IIC??

Now compare that to this:

Note that video is from the NTSB official Youtube channel - see HERE - where you will find an extensive library of 'media briefings' for other high profile accident investigations ie this is the way they do business.   

Since the Kobe Bryant media briefing, Jennifer Homendy has been appointed the Chair of the NTSB. 

Extract from the NTSB:

The Board

The NTSB has five Board Members, each nominated by the President and confirmed by the Senate to serve 5-year terms. The President designates a Board Member as Chair and another as Vice Chair for 3-year terms. The Chair requires separate Senate confirmation. When there is no designated Chair, the Vice Chair serves in an acting capacity. NTSB currently has one vacant board member seat.

The ATSB Chief Commissioner is appointed (rubber stamped) by the minister under advisement from the bureaucracy and receives zero Parliamentary scrutiny...  

Here is Jennifer Homendy's impressive biography:

Biography

Jennifer L. Homendy was sworn in as the 15th Chair of the National Transportation Safety Board (NTSB) on August 13, 2021, after being nominated by the President and unanimously confirmed by the Senate. The NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in other modes of transportation.

Chair Homendy is the agency’s chief executive, managing an annual budget of about $120 million and more than 400 full-time employees across the country, including the NTSB’s regional offices located in Anchorage, Alaska; Seattle, Washington; Denver, Colorado; and Ashburn, Virginia. She is the fourth woman to serve as Chair since the agency was created in 1967.

Chair Homendy has used her national platform to advocate for the implementation of NTSB safety recommendations, including strategies to reverse the deadly epidemic of traffic deaths, which have surged since the onset of the coronavirus pandemic. Her work has been especially focused on protecting vulnerable road users, such as pedestrians, bicyclists, motorcyclists, and people with disabilities.

As a vocal champion of the Safe System Approach, Chair Homendy speaks often about the need for a holistic approach to managing safety, preventing crashes and injuries, and saving lives on our nation’s roads — an approach that has proved successful in other transportation modes, including commercial passenger aviation.

Another of Chair Homendy’s priorities is to ensure the NTSB’s readiness to carry out its mission amid rapid technological advancement in all modes of transportation, including advanced driver assist systems, automated vehicles, commercial space transportation, uncrewed aircraft systems, advanced air mobility, supersonic aircraft, high-speed ground transportation, and clean energy sources to fuel vehicles, such as high-voltage lithium-ion batteries and hydrogen. She is pushing for measures that not only will save lives but preserve the public’s trust in proven lifesaving technologies, such as automatic emergency braking and forward-collision warning.

Chair Homendy is a staunch advocate for improving passenger and fishing vessel safety, having served as the Board Member on scene for the fire and subsequent sinking of the Conception dive boat off the coast of California in September 2019, which was the deadliest U.S. marine tragedy in recent history. She continues to push for the implementation of safety recommendations stemming from the Conception investigation, as well as NTSB investigations of the 2018 sinking of the amphibious passenger vessel Stretch Duck 7 in Branson, Missouri; the 2017 capsizing and sinking of fishing vessel Destination in Alaska; and the 2014 capsizing and sinking of fishing vessel Christopher’s Joy in Louisiana.

In aviation, Chair Homendy is focused on addressing NTSB’s long history of concerns with the safety of revenue passenger-carrying aviation operations. These operations — which include parachute jump flights as well as sightseeing flights conducted in hot air balloons, helicopters, and other aircraft — are not subject to the same maintenance, airworthiness, and operational requirements as other commercial flight operations.

Chair Homendy has served as the agency’s 44th Board Member since August 2018. She has debated and approved numerous investigation reports, provided expert testimony at the federal and state levels on a wide range of transportation safety issues, and launched with the NTSB “Go Team” on numerous investigations.

From 2004 to 2018, Chair Homendy served as the Staff Director of the Subcommittee on Railroads, Pipelines, and Hazardous Materials under the jurisdiction of the Committee on Transportation and Infrastructure (T&I Committee) of the U.S. House of Representatives. In that role, Chair Homendy was the most senior strategic advisor on safety and economic issues involving the rail industry and its employees and passengers. In addition, she was responsible for strategic advice regarding the safety of transporting oil and gas by pipeline, and transporting hazardous materials in all modes, including aviation.

Throughout her tenure on the T&I Committee, Chair Homendy successfully advocated for the inclusion of NTSB safety recommendations in relevant legislation. She was instrumental to ensuring that the 2008 reauthorization of rail programs included a requirement that positive train control (PTC) technology be installed on most of the U.S. railroad network — a safety milestone she was able to celebrate from her vantage point as an NTSB Board Member when it was fully implemented.

PTC is designed to prevent train-to-train collisions, overspeed derailments, incursions into established work zones, and movements of trains through switches left in the wrong position. NTSB estimates that PTC could have prevented 154 rail accidents that killed more than 300 people and injured more than 6,800 passengers, crewmembers, and other rail workers since 1969. In her work at the NTSB, Chair Homendy remains dedicated to improving rail worker and passenger safety.

In 2010, Chair Homendy spearheaded the T&I Committee’s extensive oversight investigations of the nation’s pipeline and hazardous materials safety program and the largest and costliest inland oil spill in U.S. history that occurred in Marshall, Michigan. She helped shape numerous laws that led to improvements in pipeline leak detection, mitigation, and emergency response, including the installation of excess flow valves on distribution pipelines. Chair Homendy continues to push for improvements in pipeline safety in her current role.

Following several high-profile transportation incidents involving the use of drugs and the rise of opioids use in the transportation sector, Chair Homendy led the T&I Committee’s 2018 multimodal, in-depth review of the U.S. Department of Transportation’s (USDOT) drug- and alcohol-testing program. The resulting report identified significant gaps in the program and made recommendations to USDOT and Congress to improve transportation safety.

Earlier in her career, Chair Homendy held a position with the International Brotherhood of Teamsters, where she represented the interests of working families before Congress and the Executive Branch, focusing on transportation (trucking, rail, and aviation) and international trade issues. She served as a classified staff liaison for the Teamsters on the President’s Advisory Committee on Trade Policy and Negotiations, the U.S. Department of Labor’s Advisory Committee on Trade, and the U.S. National Administrative Office’s North American Agreement on Labor Cooperation.

In an earlier role at the Transportation Trades Department (TTD) of the AFL-CIO, Chair Homendy spearheaded transportation labor’s efforts to reauthorize the Intermodal Surface Transportation Efficiency Act (ISTEA) and the USDOT hazardous materials safety program. Before that, Chair Homendy was with the American Iron and Steel Institute, where she advocated for the American steel industry and its employees before Congress in the areas of domestic manufacturing, transportation, environment, and energy.

Chair Homendy is an enthusiastic student of all NTSB modal areas. In addition to earning Pro Board® certification as a Hazardous Materials Responder at the Core Operations Level (with Product Control and Personal Protective Equipment Mission Specific Competencies), Chair Homendy completed Private Pilot Ground School, holds an M2 motorcycle endorsement, and is in the process of obtaining a boating license. She is also an avid runner and cyclist, which fuels her advocacy work on behalf of vulnerable road users.

Chair Homendy is a graduate of the Pennsylvania State University and is pursuing a Master of Transportation Safety Administration degree at the Institute for Global Road Safety and Security at Clemson University.

Compare that to Popinjay's BIO:

Mr Angus Mitchell
CHIEF COMMISSIONER AND CEO



Angus Mitchell has extensive experience in organisational leadership and management, maritime operations and safety investigation.

He joined the ATSB from Maritime Safety Queensland, where as General Manager he oversaw the safe and efficient movement of vessels into and out of Queensland’s 21 ports, and was responsible for compliance activities and safety investigations for Australia’s largest recreational maritime fleet.

During his tenure, Maritime Safety Queensland was recognised with an Australian Industry and Shipping Award for its role in managing international shipping throughout the COVID pandemic and supporting the welfare and safety of international seafarers.

Prior to leading Maritime Safety Queensland, Mr Mitchell was the Executive Director of NSW Maritime, where he oversaw Australia’s largest state’s primary maritime regulatory, investigative and compliance agency. He has also served as Deputy Harbour Master – Operations for Sydney Ports, where he was responsible for managing day-to-day port operations for both Sydney Harbour and Port Botany.

Angus is a former officer of the Royal Australian Navy having seen service in operational, policy and international roles. He is an Indonesian linguist and commenced his five-year term as ATSB Chief Commissioner and Chief Executive Officer on 2 September 2021.

Hmm...like chalk and cheese! - 

MTF...P2 

[Peetwo]

CHALK and CHEESE: Part II

Reference 'Accidents Domestic':

Finally: https://www.atsb.gov.au/publications/inv...o-2023-001

Mid-air collision involving two helicopters near Main Beach, Gold Coast, Queensland, on 2 January 2023

Summary

The Australian Transport Safety Bureau (ATSB) has commenced an investigation into the mid-air collision between VH-XKQ and VH-XH9 helicopters below 500 feet above ground level in the vicinity the Seaworld Helipad, QLD at about 1400 hrs EST on 2 January 2023.

VH-XKQ subsequently collided with terrain and VH-XH9 made an emergency landing. Four people were fatally injured, six sustained serious injuries, and four sustained minor injuries. The investigation is continuing.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

I am glad to see that both of the above 2 AAIs (especially the Gold Coast Seaworld chopper midair) the investigation level is defined. This suggests that the evidence collected so far (at this stage at least) points towards a fairly straight forward investigation which should be concluded fairly promptly.

It is a concern however that with all three of the above investigations it was stated that the prelim report would be released in somewhere between 6 to 8 weeks time - WTD??

Now let's compare the above intended breach by Popinjay with the Kobe Bryant NTSB investigation. 

Almost unbelievably the NTSB produced their preliminary factual report in just over 2 weeks after the accident - see HERE. 

Aircraft Accident Investigative Update

On January 26, 2020, at 0945 Pacific standard time (PST), a Sikorsky S-76B helicopter, N72EX,
collided with hilly terrain near the city of Calabasas, California. The pilot and eight passengers
were fatally injured, and the helicopter was destroyed by impact forces and fire. The helicopter
was operated by Island Express Helicopters Inc. under Title 14 Code of Federal Regulations
(CFR) Part 135 as an on-demand passenger visual flight rules (VFR) flight from John WayneOrange County Airport, (KSNA), Santa Ana, California, to Camarillo Airport, (KCMA),
Camarillo, California.

The NTSB launched a go-team consisting of an investigator-in-charge from the Major
Investigations division and specialists in operations, human performance, airworthiness,
powerplants, aerial imagery, air traffic control (ATC), meteorology, maintenance records, and
site control.

Parties to the investigation include the Federal Aviation Administration (FAA), Island Express
Helicopters, Sikorsky, and the National Air Traffic Controllers Association. The Transportation
Safety Board of Canada is participating in the investigation as an accredited representative, as is
Pratt and Whitney Canada as a technical advisor. The investigative team was also assisted on
scene by numerous other federal, state and local law enforcement and public safety agencies.
The wreckage was located in the foothills of the Santa Monica mountains, in a mountain bike
park. The impact site was on an approximate 34⁰ slope. The impact crater was 24 feet-by-15 feet
in diameter and 2 feet deep.

Here is an excellent media review of that report (courtesy Plane & Pilot) -  : 

Going Direct: NTSB Preliminary Report On Kobe Bryant Crash. Why The Big Surprise Is No Surprise At All To Pilots

By Isabel Goyer UPDATED FEBRUARY 11, 2020


Camera image of the Kobe Bryant crash site. NTSB

The NTSB preliminary report on the crash that claimed the lives of former basketball superstar Kobe Bryant and his daughter Gianna, along with seven other people, is out. The details, including the photographs, are shocking. But to people who have witnessed, studied and reported upon such tragedies, they are not unexpected. The magnitude of the physical forces associated with the crashes of aircraft at high speed and out of control into terrain defies easy understanding. So the efforts of people—the women and men who investigate these disasters—including those of our own NTSB—the greatest accident investigative body in the world—should never go unrecognized. As is the case with many governmental organizations, the NTSB has limited resources, which they allocate as best as they can. Sometimes they don’t do enough. Sometimes, as when an airplane simply vanishes, there’s not enough evidence to do anything but put together timetables and engage in a high-tech educated guessing.

Such was not the case with the flight of N72EX—the Sikorsky S-76 twin-turboshaft, nine-passenger helicopter carrying nine human beings, including one of the most well-known people on the planet—the resources were simply there. People wanted answers, and it is not in the NTSB’s DNA not to provide them. Nor is it outside of their abilities to target expenditures selectively, as they have with high-profile accident investigations through the decades.


Radar/ADS-B Track of the helicopter that Kobe Bryant and eight others were on. NTSB

With that in mind, it was to be expected that the NTSB brought its remarkable skills, resources, and technology to bear upon finding the cause of the accident. At the time of the release of the preliminary accident report, the docket containing all of materials related to the NTSB’s probe into the mishap contained more than 3,000 written pages, hundreds of photographs, video recordings, drone re-enactments of the flight and millions of data points on the flight, the weather at the time of the flight, along with recordings of the exchanges between the pilot, Ara Zobayan, and air traffic controllers along his route of flight. Keep in mind that this is the preliminary, factual report on the accident. The final report, which contains the NTSB’s statement of probable cause, usually comes out about a year after the accident.

The factual report is remarkable for its thoroughness, yes. But perhaps the big takeaway in spite of all the noise is this: There are no real mysteries behind this crash. If anything, what is most haunting about it is that for its reams of printed pages and gigabytes of data, the preliminary report leads us back to the same best guess many of us made upon first learning of the bare details of the crash that Sunday morning more than two weeks ago. That is, the crash had all the hallmarks of one of the most common and preventable accident types, what is known in the aviation community as “continued VFR (visual flight rules) into IMC (instrument meteorological conditions).”

The mainstream media’s fascination with the fact that the NTSB found there was no engine failure based on its examination of the debris is, frankly, laughable. How incredibly unlikely would it have been that when lost in the fog in mountainous terrain— while flying a complex machine by reference to the outside world, which has just disappeared from view—that at the very moment you’re about to hit the ground unless you do something outside of the regulations to avoid it, both engines in your helicopter fail? Adding to that improbability is that the pilot never mentioned engine trouble during the flight, and there is no record of any concerns over the condition of the engines before the flight. The lack of evidence of engine failure was not news.

What is news is that the factual data support the theory that the crash was mostly like a VFR into IMC mishap. In such accidents, a pilot who is flying in clear weather under visual flight rules begins to encounter cloudy skies that would legally require the flight be flown under instrument flight rules, which requires special permission, called a “clearance,” from air traffic controllers.

The danger is that pilots will, and in fact often do, lose spatial orientation, becoming unable to control the aircraft by reference to the instruments alone, once visual cues we normally use for keeping the aircraft under control are lost. Once control is lost, the rapid onset of a catastrophic loss of control incident is often, I would venture to say, almost always impossible to counteract. In layman’s terms, in many cases, once the aircraft begins to go badly out of control, that loss of control quickly becomes unrecoverable and catastrophe follows.

The mystery at the time for aviation experts, including myself, was why the pilot did not make the flight under instrument flight rules, which as an experienced, commercial pilot we all assumed—and rightfully so, as it turned out—he was trained to do and proficient at. We did not know that the company operating the flight, Island Express, did not have instrument flight authorization as part of its operating certificate with the FAA. I was surprised when a few days later I learned that few, if any, Southern California charter companies had such approval because, it has been reported, the cost and complexity of earning them and flying under IFR is prohibitive to both charter company and charter customer.

So, no, I wasn’t surprised to read the details of the NTSB preliminary report. The gist is that Zobayan flew into worsening weather conditions of low visibility, lost visual reference to the ground, got lost and probably disoriented and in the process lost control of the helicopter, which crashed at high velocity into high terrain he had stumbled into. It’s an accident type as old as aviation itself.

But a VFR into IMC accident as prominent as this one should serve, in fact, needs to serve, as a call to action among all in aviation to find ways to eliminate such mishaps, which so often result in catastrophic crashes, as this one did.

Hmm...the clock is ticking Popinjay?? 

MTF...P2 

[Peetwo]

CHALK & CHEESE: Part III

Coming back to the NTSB Calabasas Chopper crash investigation, NTSB Member Jennifer Homendy conducted a further and final press conference with the IIC and fellow member the following day IE 2 days after the accident. I very much suggest a watch and learn by Popinjay and those interested in how to professionally get ahead of the media narrative and therefore the speculation surrounding such a high profile accident (ps Note the tag teaming by Homendy and the IIC Bill English. Also note the no fluff promise of exactly 12 days for the release of the preliminary factual report)...  :

That's how it is done!   

Now compare that to this from Popinjay prior to the 'official' presser... : 

I also know that Popinjay did at least one more of these impromptu interview cuts with Skynews prior to the official presser. Note that with none of these media takes was Popinjay supported in anyway by his IIC or fellow commissioners...  

Note also that Popinjay never broke down the official investigative process or expected timeline of the investigation. The only reference to the expected preliminary report release was in his media statement on the day of the accident: https://www.atsb.gov.au/media/2023/gold-...-collision

“The ATSB anticipates publishing a preliminary report detailing basic information gathered during the investigation’s evidence collection phase in approximately 6-8 weeks..." 

Although he probably had the perfect excuse for hanging around, Popinjay didn't follow up with an update (flanked by his team, with a chance to put out speculative spot fires) on the progress of the investigation the following day?? 

In fact the only other investigative body that held an official presser the following day was the Chief Commissioner of the QLD police...

Haven't seen the whole presser but I note she mentions 'crime 'scene' and 'exhibit area' with strong indications the QLD police are firmly in control of the scene? No mention of the ATSB either? Hmm...turf war perhaps??

Compare that to the NTSB reference to the FBI helping to provide manpower for the on ground search for physical evidence - like CHALK and CHEESE? You BET! 

MTF...P2 

[Peetwo]

Wrangler chopper fatal goes systemic...err why?? 

Excellent pick up by Kristen Shorten  , via the Oz -  :

Outback Wrangler chopper probe upgraded



By KRISTIN SHORTEN
INVESTIGATIVE JOURNALIST
@itsKShort
7:11PM JANUARY 13, 2023

The Australian Transport Safety Bureau has upgraded its investigation into the fatal helicopter crash that killed Outback Wrangler cast member Chris Wilson and delayed the release of its final report into the incident by up to six months.

After almost 11 months of work, the ATSB this week quietly upgraded its investigation from “defined” to “systemic”, which means it is now looking at “organisational processes, systems, cultures and other factors” and expects to identify “several safety issues” in its final report.

Wilson, 34, was killed when the Robinson helicopter from which he was dangling during a crocodile egg-collecting mission crashed in a remote part of West Arnhem Land, in the Northern Territory last February.

The father of two had been strapped into a harness attached to a 30m line to collect crocodile eggs when the chopper hit terrain about 30km south of South Goulburn Island. Pilot Sebastian Robinson, who suffered severe spinal injuries, is still recovering.

The destroyed R44 Raven II, registered VH-IDW, was owned and operated by Outback Wrangler star Matt Wright’s company Helibrook.

Mr Wright flew to the scene immediately after the crash with Darwin publican Mick Burns, who owns the crocodile-egg harvesting business, and former senior NT policeman Neil Mellon.

Multiple agencies – including the ATSB, the Civil Aviation Safety Authority, NT Police and NT WorkSafe – are still scrutinising what happened before, during and after the fatal crash.

The ATSB’s investigation was originally considered “defined” but was last week upgraded to “systemic”, which has a broader scope, involves “significant effort collecting evidence across many areas” and often spans multiple organisations.

“Occurrences and sets of transport safety occurrences investigated normally involve very complex systems and processes,” the ATSB website says.

“In addition to investigating failed and missing risk controls, systemic investigations may also investigate the organisational processes, systems, cultures and other factors that relate to those risk controls, including from the operator, regulator, and certifying and standards authorities.”

Systemic investigations are only one level below “major” ­investigations, which is the most serious category and reserved for incidents involving many casualties.

The national transport safety investigator had originally planned to release its final report into the incident by the end of last year but this week pushed the deadline for publishing its findings to June.

This comes as the three men charged in relation to the crash are due back in court on January 25.

NT Police charged Mr Wright in November with attempting to pervert the course of justice, ­destroying evidence, fabricating evidence, unlawfully entering a building, unlawfully entering a dwelling, making a false declaration and interfering with witnesses in a criminal investigation or court process by making threats/reprisals.

The charges relate to the ­celebrity croc-wrangler’s actions after the chopper crashed and ­include allegations that he tampered with evidence at the remote crash site. The 43-year-old has denied any wrongdoing.

In September bush helicopter pilot Michael Burbidge, who was on the crocodile egg-collection mission and discovered the downed chopper before landing at the scene, was charged with conspiracy to pervert the course of justice, attempt to pervert the course of justice, destruction of evidence and providing a false statement in a statutory declaration.

Mr Mellon was charged in ­August with more than 30 offences, including making a false statement, the destruction of evidence and conspiracy to pervert the course of justice.

Note that on the ATSB webpage for this accident - see AO-2022-009 - there is no longer any date stamp (at the bottom of the page to indicate) there has been an update. Nor is there any statement in the text indicating an update, just the change in the 'investigation level' to 'systemic' and possibly a change to the 'anticipated completion' to Q2 2023?? So it is an excellent pick up by Kristen but the fact that it takes an investigative journo to discover such significant changes to a ATSB accident investigation is simply not good enough.

Here was the media statement that accompanied the 20 day late preliminary report:

The ATSB has released a preliminary report from its on-going investigation into a fatal accident involving a Robinson R44 helicopter at King River, in the Northern Territory’s West Arnhem Land.

The report notes the helicopter was one of three conducting crocodile egg collection, able to carry a crewmember (‘sling person’) attached to a 100 ft long line to access crocodile nests.

All three helicopters had departed a staging area at King River to start egg collection from nearby nests on the morning of 28 February 2022.

“Crewmembers of the other two helicopters became concerned when they had not heard any radio communications from the third helicopter,” ATSB Director Transport Safety Stuart Macleod said.

One of the pilots elected to return to the area the third helicopter was operating in, and found the wreckage at a paperbark swamp approximately 300 m from the staging area.

The sling person was found approximately 40 metres from the main wreckage, and was fatally injured. The pilot was seriously injured, and was airlifted to hospital.

“Preliminary analysis of the site by ATSB investigators indicated the accident sequence had occurred while the helicopter was travelling in a north-west direction, shortly after it left the staging area,” said Mr Macleod.

“Initial assessment indicated the engine had stopped prior to the helicopter colliding with the ground,” Mr Macleod continued.

There was no visible damage to the tail rotor blades and drive system and flight control continuity was established.

An examination of the engine and associated components found no defects likely to result in engine stoppage. The helicopter’s two fuel bladder tanks were intact despite breaches of the surrounding metal tanks, and there was no fire.

After initial assessment, the wreckage was removed from the site, and ATSB investigators drained about 250 ml of fuel from the main tank’s bladder.

It was possible fuel escaped into the creek that flowed beneath the wreckage as the fuel system was compromised in the accident, the report notes.

“This preliminary report details factual information established in the investigation’s early evidence collection phase, and as such does not detail analysis or findings, which will be outlined in the investigation’s final report,’ Mr Macleod said.

“As the investigation progresses, the ATSB will include review and examine of electronic components retrieved from the accident site.

“Fuel system components, refuelling practices and fuel quality will also be reviewed and examined, as well as relevant maintenance records, operational documentation and regulations.”

Survivability aspects of the accident will also be considered.

Read the report: AO-2022-009 Collision with terrain involving Robinson R44, VH-IDW King River, Northern Territory, on 28 February 2022

Publication Date
19/04/2022

---

Further investigation

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

• electronic components retrieved from the accident site
  
• fuel system components
  
• refuelling practices
  
• fuel quality
  
• maintenance records
  
• operational documentation
  
• regulations
  
• survivability aspects.
  

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.

All of the above indicates (other than perhaps some regulatory issues IE CASA's job to investigate) to me a fairly straight forward 'defined' investigation. So what's changed to justify an expensive taxpayer funded (100s of thousands of dollars??) upgrade to this investigation?? 

MTF...P2 

[Peetwo]

CHALK & CHEESE: AAIB v ATSB 

While the UK's AAIB operate in a very different way to the NTSB (IE low key, low profile and below the media radar) they are IMO equally as efficient and professional while not shirking their responsibilities to any sectors of the aviation industry. For example check this out off Linkedin in recent days:

 

Air Accidents Investigation Branch - UK (AAIB)
1,199 followers
1d •  1 day ago

Today we published two Field investigation reports into general aviation accidents involving gliders.

One involved a Grob G103C Twin III Acro (G-CFWC) which stalled and collided with trees at Usk Airfield, Monmouthshire on 13 June 2022.

The accident occurred during a simulated failed winch launch. The glider was initially flown away from the airfield at a low height and, whilst turning back to land, stalled and collided with trees on the edge of the airfield. Both occupants were seriously injured.

As a result of the investigation, safety action has been taken with the assistance of the British Gliding Association to improve the gliding club’s operations. The report can be viewed here:
https://lnkd.in/e4gQePDn

The other was a fatal accident involving a DG-300 Elan (G-CKJH) near Winchcombe, Gloucestershire, 7 July 2022.

At the end of a gliding day, the pilot decided to land in a field. The field he chose was uphill with a rough surface, which the pilot had not fully appreciated until he had committed to the landing. On the first touchdown, the aircraft landed heavily and bounced. The aircraft ended up in a stock fence and the pilot felt his neck had been injured. He was able to extract himself from the aircraft, but after a few steps, he began to lose feeling in his limbs and fell to the ground. Having been discovered by the landowner, he was flown by air ambulance to hospital, where he had a vertebrae fracture and a large haematoma pressing on his spinal cord. Despite recovering feeling in his limbs, complications from his injuries and underlying health conditions led to the pilot’s death 20 days later.

The investigation found no defects to the aircraft and given the experience of the pilot, the choice of field was out of character. However, the position of the sun, the size and colour of the other fields as well as the possibility of dehydration during a warm day may have contributed to the pilot’s decision making.

The report can be viewed here:
https://lnkd.in/eKeJ2Sjm

#aviationsafety #safety #generalaviation

Meanwhile Popinjay's mob can't even be bothered (with the excuse that he doesn't have the necessary resources and there is no 'new learnings') to investigate a midair collision involving a VH registered glider?? - FDS!     

MTF...P2 

[Peetwo]

CHALK & CHEESE: Talking out of school?? 

On the comparative timeline, 2 weeks after the Calabasas chopper accident the Preliminary report was released without any further fanfare. Just this news release: 
 

NTSB Issues Investigative Update on Sikorsky Helicopter Crash

2/7/2020

The National Transportation Safety Board issued an investigative update Friday for its ongoing investigation of the fatal, Jan. 26, 2020, helicopter crash near Calabasas, California.

The Sikorsky S-76B helicopter collided with hilly terrain and was destroyed by impact forces and fire. The pilot and eight passengers were fatally injured. The helicopter operated by Island Express Helicopters Inc., was on an on-demand passenger visual flight rules flight from John Wayne-Orange County Airport, in Santa Ana, California, to Camarillo Airport, in Camarillo, California.

"Our investigators have already developed a substantial amount of evidence about the circumstances of this tragic crash," said NTSB Chairman Robert L. Sumwalt. "And we are confident that we will be able to determine its cause as well as any factors that contributed to it so we can make safety recommendations to prevent accidents like this from occurring again.” 


(This NTSB still image is from a drone video duplicating the flightpath of N72EX at position/altitude of last ADS-B target. NTSB image)

According to the investigative update, all significant components of the helicopter were located within the wreckage area. Examination of the main and tail rotor assemblies found damage consistent with powered rotation at the time of impact. The initial point of impact consisted of highly fragmented cabin and cockpit debris.

The main wreckage was about 127 feet from the impact and consisted of the empennage/tailboom, both engines, avionics boxes, and portions of the cockpit instrument panel. The entire fuselage/cabin and both engines were subjected to a postcrash fire. The cockpit experienced extreme fragmentation. The instrument panel was destroyed, and most instruments were displaced from their panel mounts. Flight controls were fragmented and fire damaged.

The helicopter was not equipped with a flight data recorder or cockpit voice recorder nor was it required to be for the accident flight. The NTSB has been issuing recommendations to the Federal Aviation Administration to require recorders on helicopters since 1999. Currently, safety recommendations A-13-12 and A-13-13 are the only open recommendations that address recorders in helicopters.

The helicopter operator, Island Express Helicopters, held an FAA Part 135 operating certificate ISHA094F, for on-demand VFR-only operations, since 1998 and conducted offshore oil industry support flights and charter flights. The company’s operations specifications document listed six helicopters including the accident aircraft: 1 SK-76A, 2 SK-76B, 2 AS-350-B2 and 1 AS-350-BA.

The investigative update includes a summary of the ATC and radar data, weather information as well as a summary of video and photos provided by witnesses depicting the weather at the time of the accident.

The information in the update is preliminary and subject to change as the NTSB’s investigation progresses. Analysis of the accident facts, along with conclusions and a determination of probable cause, will come at a later date when the final report on the investigation is completed. As such, no conclusions about how the incident happened should be drawn from the information contained within the investigative update.

The full investigative update is available at https://go.usa.gov/xd84a

Additional information about this investigation is available on the accident webpage: https://go.usa.gov/xd8ah

To report an incident/accident or if you are a public safety agency, please call 1-844-373-9922 or 202-314-6290 to speak to a Watch Officer at the NTSB Response Operations Center (ROC) in Washington, DC (24/7).

Meanwhile on the Gold Coast chopper midair accident there is no 'investigative update' (prelim report/interim factual statement) from the ATSB. And according to Popinjay we should not expect one for at least another 3 to 5 weeks, at the earliest?? -   

However 2 days ago there was this squeak, apparently attributed to Popinjay...  : 

Via 1News NZed: 

Questions over leak of Gold Coast helicopter crash footage remain

By Andrew Macfarlane, 1News Australia Correspondent
Mon, Jan 23

Australia’s air safety investigator has carried out a review into whether footage of the fatal helicopter crash on the Gold Coast was leaked from someone in the organisation.

New Zealanders Edward Swart, Marle Swart, Riaan Steenberg and Elmarie Steenberg were on a scenic helicopter ride near SeaWorld when their aircraft collided with another one taking off from below in early January.

While the holidaymakers miraculously survived, four others were killed in the tragedy.

Now there are fresh questions over how footage from inside one of the helicopters was released to media, without the permission of survivors.

The video, which shows the moments before the collision, was first aired by Australian broadcaster Channel 7, with the group of New Zealanders telling 1News they hadn’t shared the footage and that they were seeking legal advice.

Chief commissioner for The Australian Transport Safety Bureau (ATSB) Angus Mitchell told 1News the broadcast of the footage was “distressing and inappropriate”, but it hadn’t come from the ATSB.

He said the leaking of evidence is concerning and against Commonwealth law in Australia.

“Evidence such as the videos provided by passengers is protected under Commonwealth law as restricted information, and can only be released on my authority as the chief commissioner for the purposes of improving transport safety.”


The New Zealand survivors of the fatal Gold Coast helicopter crash. (Source: Supplied)

Mitchell said he was confident the footage hadn’t been shared by an ATSB staff member, following an internal investigation.

“To be able to provide that assurance to others, on learning of the footage being aired in the media I immediately ordered a review of the ATSB’s IT systems, including any mobile devices, on which that footage was held.”

“That review showed no evidence that the footage had been shared externally by anyone at the ATSB.”

There are also concerns that the leak could compromise future investigations, and the sharing of sensitive information.

1News also asked the Queensland Police for similar reassurances, as they are the other major organisation involved in the investigation.

A spokesperson said “the incident is subject to ongoing Coronial investigations, it would be inappropriate to provide further comment, as all aspects of the matter are being examined as part of investigations.”

Note the difference between Popinjay flapping his gums to an 1News reporter and the short but succinct statement from a QPS spokesperson...

A quick review of the 'attributed' to Popinjay media statement webpage - see HERE - or on social media do not acknowledge any of the above statements from Popinjay - WTD??   

MTF...P2 

[Gentle]

Australia Day Honours 2023

Mr Gregory James HOOD AO



For distinguished service to the national transportation and aviation industries, and to the not-for-profit sector



“Not a knighthood like others as AsA Chair (Angus) but surely a requirement if he is to be promoted?”

Uhm; is that fires burning and cauldrons bubbling I hear? (a beat) - Ayup, I'd say so........

[Peetwo]

UDB?? - An AO for HVH...

Ref: 

Australia Day Honours 2023

Mr Gregory James HOOD AO



For distinguished service to the national transportation and aviation industries, and to the not-for-profit sector



“Not a knighthood like others as AsA Chair (Angus) but surely a requirement if he is to be promoted?”

Uhm; is that fires burning and cauldrons bubbling I hear? (a beat) - Ayup, I'd say so........

Via the AP email chains:

---

How is it the guy who fudged/dodged his responsibilities as the CASA Executive Manager Operations and 'decision maker' in the McComic led CASA embuggerance of Dominic James and Rob Couch (plus probably numerous others). And the guy who threatened his employees, as the Chief Commissioner of the ATSB with criminal sanctions of up to 2 years jail under the TSI Act, if they were to speak out of school on the ATSB underwater search for MH370, receives a GONG (AO) for 'distinguished service to national transportation and aviation industries'...retch..spew - UDB??   

MTD...P2