[Kharon]

The land of Nod.

“The biblical Nod was a place of anguished exile rather than of peaceful sleep. It is mentioned right at the beginning of the Bible and is located 'East of Eden' and it is where Cain dwelt after being cast out by God after Cain's murder of his brother Abel. The name Nod was chosen with a purpose. 'Nod' (נוד) is the Hebrew root of the verb 'to wander' (לנדוד). The implication is that Cain, being in disgrace, was sent to wander aimlessly.”

And an unmentionable line of investigation for which PAIN has been carefully collecting and compiling anecdotal evidence to support what began as a notion, which is developing into a theory, is well, unmentionable. It will take a little while longer to gather and test enough data to make it stick; but there is no rush. Indeed the data may not make it to report stage – there is no one to send a report to; well no one who could or even would do anything about the situation. It goes something like this:-

There have been some horrific, fatal accidents during crew check and training (C&T) exercises; the Braz in Darwin and the Ross Air event in SA. There have also been some very close calls which have not made the headlines. There is also a body of evidence which, in our opinion demands a deeper look into why experienced, senior C&T pilots with qualified crew have had their lives ended in ‘training’ exercises. At present, it is a tangle of anecdote, complaint and clumsy, half baked arse covering legislation where ‘theory’ and good intentions meet with the pedantic. But, FWIW here are some of the ‘bare bones’.

Simulators for the large commercial aircraft are extremely good and they most definitely provide a sound, solid training and checking regime; no question about it. Then we move down the scale to the less salubrious operations using a lower certification and maintenance standard. Which is fine for systems and procedures training and emergency drills etc. But do they truly represent the aircraft – in flight – in a real emergency. The fact is they do not, not by a long shot. This is where it becomes ‘dangerous’.

Enter the dragon. There are tales that some CASA FOI are insisting that the simulating of Emergencies is done in the aircraft exactly as they are in the Sim. There are also tales of ‘dual systems’ failure being used in real life – for example; a failed Auto feather system and V1 cut at ‘book speeds’. (Figure the chances of an AF failure during the seconds the aircraft is actually at V1 – it less than one second). Fine and dandy in the Sim – but in real life? Seriously. The RAAF lost a 707 through ‘Machismo’ way back and yet in the modern era we hear stories of similar idiot behaviour. Then, we get to the very real differences between a low Cat Sim and the stark realities of EP. I’ll tell you a story which is absolutely true.

A Sim instructor demonstrated an EFATO – from V1. Easy Peasy, his feet neatly tucked away under the seat, one hand on the controls – one on the quadrant. Bang – V1 cut – casually, the rudder trim was spun to full deflection, the engine shut down and without even placing his feet on the rudders, with one hand flying, the other is his lap, the Sim was pedalled about the circuit and landed. I defy anyone to do this in that aircraft. Anyway - one of the Sims candidates turned up for a routine IR/ Base check; was carefully briefed on what was to happen, when and etc. Off they went – the briefed EFATO occurred as discussed. The failed engine was identified and, the rudder trim ‘actioned’ as per Sim training – the left turn onto crosswind was managed from about 40˚ off centreline, the feet came off the unmoving pedals and the aircraft flew a perfect half of a figure of Eight; over the field, cross controlled, fetching up on a right base for the other end of the departure runway. “Taking over” was the call.

P7 Addendum: You forgot to mention the second happened in an aircraft - for real...........

The point of all this ramble is a simple one. There’s stuff you can do in a Sim, without consequence. All great training and provided the Sim is as representative of the aircraft as possible all is well. But; when CASA FOI begin insisting, without a reality check that the aircraft will represent the Sim and expect the same level of safety – then questions must be asked.

Thankfully, one of the great exponents of this thinking has retired from CASA; much to everyone’s relief. I think we have seen enough accidents now to justify an in depth analysis. If only there was somewhere to send it – where someone actually gave a Duck about operational safety as opposed to the ‘legal’ version.

Perhaps the ATSB have stumbled across something along these lines and don’t know what to do with the information; or, where to take it. Resignation the only option for a honourable tin kicker. We’ll never know.

Toot – toot.

[Choppagirl]

Kharon, you have summed up the main argument I hope to present at a future inquest. If and when the ATSB ever complete their investigation into the Rossair crash. I want to know why it is acceptable to "practice" EFATO at 400 feet in Australia when the UK and USA insist on 3000 feet. Unfortunately, I feel that you are correct and the problem will be that no one will listen and nothing will change.

[Kharon]

Feely – Touchy? Tin Hat?

CG – “I want to know why it is acceptable to "practice" EFATO at 400 feet in Australia when the UK and USA insist on 3000 feet.”

Some aircraft; of which I have a little more than a nodding acquaintance, are grossly misrepresented in the ‘Grand-Fathered’ simulator approvals. In fact, recently I have flown three individual simulators which, IMO, are so far removed from ‘reality’ that apart from ‘systems’ and procedural training, they are as far as it is possible to get from ‘the aircraft’.

As said; they are great for sorting multi crew operations into a routine and a thinking pattern; fantastic for analysing a series of lights and warnings; very good at demonstrating how one failure can lead to another etc & etc. No quarrel with any of that, indeed I would support the notion that ‘Sim’ training is cost effective and valuable. But, it is not the end of the Rainbow. Not by a long march.

Much depends on the Sim operator. There are some who will ‘tick-a-box’ and, provided the client company is happy with this outcome, then all is well. No come-back in the event of an accident. Then, you have operations in the class of Flight Safety; these guys are good. Their simulators and their tech support is fantastic; their Sims as close as possible to ‘reality’ and they can talk to the FAA about what’s best and fairest. If the world followed the FS ethic and philosophy, I would not be banging on here. Alas…

The ‘quality’ is not in the ‘movement’ or the ‘visuals’ the quality is based on the amount of expense the provider is prepared to go to in order to achieve a realistic flight envelope. The ‘low end’ provider will take the data fro one test flight envelope as use that as the ‘base’ for the software. Folk like FS will take (pay for) all the flight envelope data they can get and spend as much time and money as they can on getting the aircraft simulator ‘right’. Small things. like synchronising the visuals with movement is incredibly time and money consuming.

Many don’t care about the accuracy of simulation. They want pilots in and out in the shortest time acceptable at minimum cost. The oldest and most hoary of faery tales s “just get it done in the Sim” we’ll teach you fly the aircraft later. Qualified – Oh yes. Safe? Well that would depend on reliability and Lady Luck.

There is defined ‘gap’ between be legally qualified and operationally competent in some ‘training’ programmes.

There exists a confusion within official minds that the Sim can make for a ‘safer’ pilot. This notion will only be tested when pilots begin to say the magic word “No”. Or in my case “No Way” to some of the outlandish demands of CASA FOI who expect an aircraft to behave in exactly the same fashion as the Sim.

Back in the day – even Qantas required that any qualifying check was conducted ‘in the aircraft’. No so much today – but Sim’s have improved, particularly at airline level so this, in a controlled environment is acceptable. Down stream, from top class airlines – things are not so cut and dried. Therein lays the quandary.

For example – the Conquest Negative Torque System (NTS). If the engine is not sensing ‘negative torque’ then the system will not (Categorically) work – it cannot. Therefore, simply simulating an engine failure will produce a ‘worst case’ scenario i.e. a propeller at full flight fine pitch – as in a barn door on one side. The rate of speed wash off is well documented in the certification data, along with the ‘sloppy’ low speed aileron/ elevator effectiveness. Cool in the Sim;-but in real life? Seriously? Once again CASA’s legal arse end covered – the bodies are of no significance. Lord have Mercy…

Toot – toot.

[Kharon]

Feely – Touchy? Tin Hat?

CG – “I want to know why it is acceptable to "practice" EFATO at 400 feet in Australia when the UK and USA insist on 3000 feet.”


Good question. Some aircraft; of which I have a little more than a nodding acquaintance, are grossly misrepresented in the ‘Grand-Fathered’ simulator approvals. In fact, recently I have flown three individual simulators which, IMO, are so far removed from ‘reality’ that apart from ‘systems’ and procedural training, they are as far as it is possible to get from ‘the aircraft’.  Taxi and Tin Hat about now......But I'll stand by it.- FWTW.

As said; they are great for sorting multi crew operations into a routine and a thinking pattern; fantastic for analysing a series of lights and warnings; very good at demonstrating how one failure can lead to another etc & etc. No quarrel with any of that, indeed I would support the notion that ‘Sim’ training is cost effective and valuable. But, it is not the end of the Rainbow. Not by a long march.

Much depends on the Sim operator. There are some who will ‘tick-a-box’ and, provided the client company is happy with this outcome, then all is well. No come-back in the event of an accident. Then, you have operations in the class of Flight Safety; these guys are good. Their simulators and their tech support is fantastic; their Sims as close as possible to ‘reality’ and they can talk to the FAA about what’s best and fairest. If the world followed the FS ethic and philosophy, I would not be banging on here. Alas…

The ‘quality’ is not in the ‘movement’ or the ‘visuals’.  The quality is based on the amount of expense the provider is prepared to go to in order to achieve a realistic flight envelope. The ‘low end’ provider will take the data from one test flight envelope as use that as the ‘base’ for the software. Folk like FS will take (pay for) all the flight envelope data they can get and spend as much time and money as they can on getting the aircraft simulator ‘right’. Small things. like synchronising the visuals with movement is incredibly time and money consuming.

Many don’t care about the accuracy of simulation. They want pilots in and out in the shortest time acceptable at minimum cost. The oldest and most hoary of faery tales is “just get it done in the Sim” we’ll teach you fly the aircraft later. Qualified – Oh yes. Safe? Well that would depend on reliability and Lady Luck.

There is defined ‘gap’ between be legally qualified and operationally competent in some ‘training’ programmes.

There exists a confusion within official minds that the Sim can make for a ‘safer’ pilot. This notion will only be tested when pilots begin to say the magic word “No”. Or in my case “No Way” to some of the outlandish demands of CASA FOI who expect an aircraft to behave in exactly the same fashion as the Sim.

Back in the day – even Qantas required that any qualifying check was conducted ‘in the aircraft’. Not so much today – but Sim’s have improved, particularly at airline level so this, in a controlled environment is acceptable. Down stream, from top class airlines – things are not so cut and dried. Therein lays the quandary.

For example – the Conquest Negative Torque System (NTS). If the engine is not sensing ‘negative torque’ then the system will not (Categorically) work – it cannot. Therefore, simply simulating an engine failure will produce a ‘worst case’ scenario i.e. a propeller at full flight fine pitch – as in a barn door on one side. The rate of speed wash off is well documented in the certification data, along with the ‘sloppy’ low speed aileron/ elevator effectiveness. Cool in the Sim;-but in real life? Seriously? Once again CASA’s legal arse end covered – the bodies are of no significance. Lord - have Mercy…

Toot – toot.

[Peetwo]

Feely – Touchy? Tin Hat?

CG – “I want to know why it is acceptable to "practice" EFATO at 400 feet in Australia when the UK and USA insist on 3000 feet.”


Good question. Some aircraft; of which I have a little more than a nodding acquaintance, are grossly misrepresented in the ‘Grand-Fathered’ simulator approvals. In fact, recently I have flown three individual simulators which, IMO, are so far removed from ‘reality’ that apart from ‘systems’ and procedural training, they are as far as it is possible to get from ‘the aircraft’.  Taxi and Tin Hat about now......But I'll stand by it.- FWTW.

As said; they are great for sorting multi crew operations into a routine and a thinking pattern; fantastic for analysing a series of lights and warnings; very good at demonstrating how one failure can lead to another etc & etc. No quarrel with any of that, indeed I would support the notion that ‘Sim’ training is cost effective and valuable. But, it is not the end of the Rainbow. Not by a long march.

Much depends on the Sim operator. There are some who will ‘tick-a-box’ and, provided the client company is happy with this outcome, then all is well. No come-back in the event of an accident. Then, you have operations in the class of Flight Safety; these guys are good. Their simulators and their tech support is fantastic; their Sims as close as possible to ‘reality’ and they can talk to the FAA about what’s best and fairest. If the world followed the FS ethic and philosophy, I would not be banging on here. Alas…

The ‘quality’ is not in the ‘movement’ or the ‘visuals’.  The quality is based on the amount of expense the provider is prepared to go to in order to achieve a realistic flight envelope. The ‘low end’ provider will take the data from one test flight envelope as use that as the ‘base’ for the software. Folk like FS will take (pay for) all the flight envelope data they can get and spend as much time and money as they can on getting the aircraft simulator ‘right’. Small things. like synchronising the visuals with movement is incredibly time and money consuming.

Many don’t care about the accuracy of simulation. They want pilots in and out in the shortest time acceptable at minimum cost. The oldest and most hoary of faery tales is “just get it done in the Sim” we’ll teach you fly the aircraft later. Qualified – Oh yes. Safe? Well that would depend on reliability and Lady Luck.

There is defined ‘gap’ between be legally qualified and operationally competent in some ‘training’ programmes.

There exists a confusion within official minds that the Sim can make for a ‘safer’ pilot. This notion will only be tested when pilots begin to say the magic word “No”. Or in my case “No Way” to some of the outlandish demands of CASA FOI who expect an aircraft to behave in exactly the same fashion as the Sim.

Back in the day – even Qantas required that any qualifying check was conducted ‘in the aircraft’. Not so much today – but Sim’s have improved, particularly at airline level so this, in a controlled environment is acceptable. Down stream, from top class airlines – things are not so cut and dried. Therein lays the quandary.

For example – the Conquest Negative Torque System (NTS). If the engine is not sensing ‘negative torque’ then the system will not (Categorically) work – it cannot. Therefore, simply simulating an engine failure will produce a ‘worst case’ scenario i.e. a propeller at full flight fine pitch – as in a barn door on one side. The rate of speed wash off is well documented in the certification data, along with the ‘sloppy’ low speed aileron/ elevator effectiveness. Cool in the Sim;-but in real life? Seriously? Once again CASA’s legal arse end covered – the bodies are of no significance. Lord - have Mercy…

Toot – toot.

Addendum: It would appear that once again we are going down the (very scary) MOAS black hole...  Therefore for the benefit of CG, plus those curious in the aviation safety embuggerance timewarp in this country, could i suggest a simple search word be placed into the AP search function - ie Brasilia : https://auntypru.com/forum/search.php?ac...order=desc

Now scroll to the bottom of the page and slowly work your way up...

The following quotes, from the 1st couple of links provided, highlights the disconnection between industry expectations of the ATSB as the so called 'aviation safety watchdog' and the reality of what the agency has become - i.e a neutered and muzzled. mangy mutt...   

..Finally the following quote from AIPA's ASRR submission perhaps highlights the view of many of Qantas pilot's (at least) in regards to having & maintaining a fully independent State AAI:

AIPA’s submission specifically questioned whether CASA’s role in the aviation system was being adequately scrutinised, but the harsh reality is that the same question could be asked in relation to any of the agencies directly or indirectly influencing aviation safety. 

Current knowledge, post the Senate Inquiry, suggests not.

AIPA believes that the ATSB has a very clear duty under the TSIA to independently and holistically examine the aviation safety system. Pandering to the ego or behaviour of any stakeholder is anathema to the principles under which the ATSB was established and AIPA strongly believes that the safety message should never be lost in the telling. We strongly support the notion of the ATSB as the watchdog of agency influence on aviation safety.

[b]Recommendation 3[/b]

AIPA recommends that the Minister for Infrastructure and Regional Development issue a directive to the ATSB clarifying that paragraphs 12AA(1)(b) and © of the Transport Safety Investigation Act 2003 require holistic examination of the aviation safety system, including the regulatory framework, and that cooperation and consultation with stakeholders must not be permitted to compromise the independence of the ATSB or the making of safety recommendations.

Nonetheless, AIPA recognises two important factors: first, the current generation of senior ATSB managers may find it difficult to step out of Miller’s shadow; and second, the ATSB is not and never should be a routine auditor of the aviation safety system. AIPA believes that the latter function requires a Machinery of Government change to redress a number of aviation safety governance issues. We will elaborate on that proposal later in this submission.

Addendum - DAS'd hopes.

The following is a link for the PAIN research & opinion piece - Opinion :-ATSB since 2003. In the course of the Senate AAI Inquiry this paper was submitted to the RRAT References Committee for their review.

The part to which AIPA reference in their submission 8 to the Committee is on pages 4 & 5.

From page 5 of PAIN report:

Opinion: This data clearly shows the demise of the Safety Recommendation in Australia but it does not mirror the ‘tremendous’ savings made by not having to administer such an essential database. Which seems to be Mr Dolan’s primary focus.

What the data also clearly shows is that the leading transport investigation authority the NTSB do not share the ATSB philosophy on the issuing of safety recommendations. The
NTSB know that safety recommendations are indeed the cornerstone of their existence and the safety information contained within recommendations will be disseminated across the aviation industry, the travelling public and indeed around the world.

The following is an excerpt of the generic ‘Safety Action’ statement issued with nearly all
ATSB Final Reports within the last two years:

SAFETY ACTION.
Whether or not the ATSB identify safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence

Opinion: Translated this means is that unless an interested party actually reads the report the safety action information contained within the report is effectively ‘invisible’ and will not be disseminated across worldwide industry stakeholders.

Generating Safety Recommendations ensures that the safety action information is totally
transparent.

PAIN has several substantial volumes of information that show the demise of the ‘Safety
Recommendation’ in Australia, such is our concern on this issue.

We have also examined the final reports on the Pel Air ditching event off Norfolk Island
and the fatal Sydney 'Canley Vale' and Darwin Brasilia fatal accidents; we believe they
provide further examples of compromised ATSB Final Reports.

Also relevant to the discussion is PAIN supplementary submission (click on title) - NGA_Senate_Supplement.pdf - to which Chapter 7 is of particular relevance...

---

&..

...CASA and ATSB; an unholy union?

It really is a hellish tangle. Layer upon layer of obfuscation, work-shopped denial, artful justification and more hyperbole than you could shake a stick at.  I am of course referring to the ATSB confection of investigation; the sweet delights found in the Beyond all Sensible Reason approach. I can’t, not with the best will in the world, do the research and reading for you. Neither can I tell you  how to ‘read’ the material. It is as stultifying, mind numbing, tedious and eye glazing, as it is intended to be.  Practical folk, like pilots (particularly) don’t read the published works of ICAO or the glossy, lengthy dribble published by the ‘agencies’; not in the way a lawyer or a judge would and certainly not in the way ICAO would. These documents are writ in different language, the language of the bureaucrat, the diplomat and the policy maker. So, one needs to dig deep and do some head scratching to translate the offerings.  Not many practical folk will– I flatly refuse to, unless there is a need. The Pel-Air report provides that need, the concerns of the Senate Standing Committee (SSC) drive that need and, IMO the industry, the minister and the travelling public need to be made aware of the dreadful state not just the ATSB is in; but the whole sorry saga of the Australian aviation oversight system, despite the ‘feel good’ rhetoric.  Shall we begin by taking a brief look at history, (the exit? - second on the left)...

    
And on the subject of simulators and CASA's causal history of blue line fever training accidents please refer here: 4D - DOT,DOT,DOT-DASH,DASH,DASH-DOT,DOT,DOT

..History then shows a clear shift in the approach of the ATSB to a ‘softly softly’ approach where organizational issues are brushed aside. A classic is the Air North Brasilia fatal where a whole string of ‘organizational’ matters of great import were written out of the script.  In short, a routine check and training flight ended with two deaths. The question left begging is why two experienced, qualified pilots died that day. The ‘new’ procedures being used were ‘approved’ by CASA, have to be. The practices used in the simulator take the aircraft into ‘borderline’ dangerous situations; which is fine, and; in theory, those practices should translate into in-flight scenario. Well, they did not. There is a CASA FOI who we believe has much to answer for, still gainfully employed, at the well hidden roots of this accident. Part of the ‘organizational’ causal chain; sure, but acknowledged? Don’t be naïve...

P2 comment: "..still gainfully employed.."   Fortunately that Worthless individual is no longer gainfully employed -     
MTF...P2 

[Choppagirl]

Interesting PAIN report:  http://auntypru.com/wp-content/uploads/2...opin_2.pdf

The most recent comparison between FAA and ATSB safety recommendations to the regulator was 2010. Does anyone know if there is any more recent research in progress?

"K" - Ayup - what's your point? Progress - Nope. Comparison - Nope. When the US Senate or the NTSB say 'fix it". FAA do exactly that. There is no comparison - "I rest my case M'Lud".....

[Peetwo]

Interesting PAIN report:  http://auntypru.com/wp-content/uploads/2...opin_2.pdf

The most recent comparison between FAA and ATSB safety recommendations to the regulator was 2010. Does anyone know if there is any more recent research in progress?

G'day Choppagirl, I was the original researcher that did the SR comparison between the FAA and the ATSB for the years 2000 to 2010. Although I have been monitoring the ATSB Aviation mode SRs since I have not been doing the same for the NTSB. However it is relatively easy to access the NTSB SR archive, see HERE. It is pretty clear from that huge database that under the 'aviation mode' (or any transport mode for that matter) that the NTSB are extremely proactive with the issuance of SRs to address many identified 'Safety Issues' in active and completed AAIs.

Compare that to the ATSB over the period from 01/01/2011 to now there has been 36 SRs issued - see HERE - of which 13 are addressed to CASA.

Hope that helps -   

MTF...P2 

[Choppagirl]

It does. Thanks very much P2!

[Choppagirl]

It would be interesting to know what aviation experience is held among members of the ATSB, especially among the expert investigators, and particularly given that a large majority of them quit last year!!! Where are they getting these experts from? I don't know of many pilots who aspire to work for them. Can't imagine why!

[Peetwo]

It would be interesting to know what aviation experience is held among members of the ATSB, especially among the expert investigators, and particularly given that a large majority of them quit last year!!! Where are they getting these experts from? I don't know of many pilots who aspire to work for them. Can't imagine why!

Can't imagine it helps much when the Hooded Canary has apparently threatened retribution under the TSI Act (i.e. 2years) if investigators so much as think about leaking or offering opinion to the outside world:  Update: Hood (ATSB) v Higgins (The Oz) & https://infrastructure.gov.au/department...dacted.pdf + https://infrastructure.gov.au/department...dacted.pdf

[Peetwo]

#ET302 v VH-FNP - Like Chalk & Cheese?

I note that yesterday there was two significant Annex 13 AAI reports made public, one was the prelim report into the tragic accident of Flight ET302 by the Ethiopian AAIB - see HERE - and the other was the ATSB final report into a Virgin Australia Regional Airlines Airbus A320 charter flight occurrence departing Perth, on 12 September 2015 - see HERE.   

Even though it is 3 years 6 months and 24 days since the VARA VH-FNP, the ATSB considered the findings and safety issues significant enough to put out the following media blurb...

Unreliable airspeed indication and stall warning

Airbus is proactively updating software on its A320 aircraft to ensure pilots receive alerts at an appropriate level of priority during periods of multiple alerts and high workload.



The update follows an ATSB investigation into an unreliable airspeed indication and stall warning involving a Virgin Australia Regional Airlines Airbus A320 near Perth Airport on 12 September 2015.

While passing through 8,500 ft, the aircraft’s autothrust and autopilot disconnected and multiple system alerts were generated. The captain took manual control of the aircraft and continued the climb to 20,000 ft, and levelled off to troubleshoot the issues and plan a return to Perth.
On approach to Perth Airport while aligning with the instrument landing system, the stall warning activated. The warning stopped after six seconds and the approach was continued for a successful landing.

The ATSB found the autothrust and autopilot disconnect was the result of erroneous airspeed indications during the take-off and climb due to blocked pitot tubes. The erroneous airspeeds were not detected by the pilots but had been detected by the aircraft’s systems, which had triggered the disconnect and generated multiple alerts including a ‘NAV ADR DISAGREE’ alert.

… it is important that alerts and procedures be designed to ensure that the pilots can correctly diagnose the source of the erroneous information…

This alert requires the pilots to crosscheck the three airspeed indications and assists them in determining if the source of the alert is an airspeed or angle of attack disagreement. However, limited space in the alert message area meant it was initially pushed off the screen for engine-related alerts programmed with a higher priority but in this case not requiring immediate action by the crew.  

The crew’s high workload meant the procedures for these alerts initially were not actioned and they were unable to address the ‘NAV ADR DISAGREE’ alert for about eight minutes, by which time the airspeed discrepancies had corrected themselves.
 
The ATSB found this sequencing of alert priorities and the alert’s associated procedure may have led the pilots to incorrectly identify the source of the alert as an angle of attack discrepancy, which the NAV ADR DISAGREE procedure advised had a risk of triggering an undue stall warning.
Combined with the multiple system alerts, which to the flight crew appeared to be unrelated, the flight crew thought the stall warning that activated during the approach was spurious and as such did not apply the stall recovery procedure. Stall warnings are triggered by angle of attack, not airspeed, and there were no indications that the angle of attack system was not functioning correctly.

ATSB Executive Director, Transport Safety, Mr Nat Nagy, said modern aircraft with multiple interacting systems can have many layers between the source information and the pilots. 

“The ATSB’s safety message from this investigation is where there is erroneous information from an information source, it is important that alerts and procedures be designed to ensure that the pilots can correctly diagnose the source of the erroneous information,” Mr Nagy said.
“Further, unless it is absolutely clear that it is erroneous, pilots should appropriately respond to stall warning alerts.”  

Airbus is currently in the process of updating the A320’s software so that the NAV ADR DISAGREE alert has a higher priority than the associated engine alerts. In the case of multiple alerts generated by unreliable airspeed, it will take precedence over the other associated alerts and be immediately visible to the pilots.

In addition, the ‘risk of undue stall warning’ message will be removed from the aircraft status related to the NAV ADR DISAGREE alert.
Read the report: Unreliable airspeed indication and stall warning involving Airbus A320, VH-FNP, near Perth, Western Australia
 SHARE THIS PAGE  FEEDBACK
Last update 04 April 2019

These were the safety issues identified: 

Priority of NAV ADR DISAGREE alert

Although the NAV ADR DISAGREE had more immediate safety implications relating to unreliable airspeed, the ECAM alert priority logic placed this alert below the engine-related faults. As a result, the NAV ADR DISAGREE alert was not immediately visible to the flight crew due to the limited space available on the ECAM display.

Safety issue detailsIssue number: AO-2015-107-SI-01
Who it affects: Operators of Airbus A320 aircraft
Status: Adequately addressed

---

NAV ADR DISAGREE procedure

A NAV ADR DISAGREE alert can be triggered by either an airspeed discrepancy, or angle of attack discrepancy. The alert does not identify which, and the associated procedure may lead flight crews to incorrectly diagnosing the source of the alert when the airspeed is erroneous for a short period and no airspeed discrepancy is present when the procedure is carried out.
Safety issue details
Issue number: AO-2015-107-SI-02
Who it affects: Operators of Airbus A320 aircraft
Status: Adequately addressed

Strangely enough the date on these wet lettuce 'safety issues' is dated yesterday:

Eg:

Issue number: AO-2015-107-SI-01
Who it affects: Operators of Airbus A320 aircraft
Issue owner: Airbus
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2015-107
Date: 04 April 2019

Yet under the title of 'Proactive Action' it states:

..On 10 August 2018, Airbus informed the ATSB that:

… after internal review with our ECAM specialists we have decided to increase the priority of the NAV ADR DISAGREE alert.

The NAV ADR DISAGREE alert will now have a higher priority than the EPR MODE FAULT alerts.

This will insure that in the event scenario, this alert would be directly visible to the crew.

This modification will be introduced in the next FWS [flight warning system] standard for SA family, the version F12, which currently planned for Q1-2019. A worldwide retrofit is anticipated...

Plus:

..On 23 January 2019, Airbus advised the ATSB that Airbus has launched the following safety actions:

1. The priority of the NAV ADR DISAGREE alert has been increased and will now have a higher priority than the EPR MODE FAULT alerts. In scenarios similar to the event, this alert will become immediately visible to the flight crew, therefore the detectability of a transient airspeed discrepancy will be significantly improved. It is recalled that the FCTM [Flight Crew Training Manual] presents this alert as one of the typical symptoms the flight crews must have in mind in order to detect this situation early and apply the "UNRELIABLE SPEED INDICATION" QRH [Quick Reference Handbook] procedure.

2. Following the full analysis of the AoA [angle of attack] failure cases leading to the triggering of the NAV ADR DISAGREE procedure, it was decided to remove the information line “RISK OF UNDUE STALL WARN” from the ECAM status. Indeed, it corresponded only to theoretical cases not considered as realistic in service. With this modification, if a flight crew determines the source of the NAV ADR DISAGREE alert to be an AoA disagree, the risk of undue stall warning will no more be present on the ECAM and therefore the flight crew will rely on the stall warning. This will address the risk of stall and loss of aircraft control mentioned by the ATSB in the Stall warning section of this report. This modification will be introduced in the FWS [flight warning system] standard F12, conjointly with the change of the NAV ADR DISAGREE alert priority.

3. Finally, Airbus will further enhance the detection of the unreliable airspeed situations with the introduction of the Unreliable Airspeed Mitigation Means (UAMM) function. In the event scenario, the ECAM should display the NAV ALL SPD UNCERTAIN red warning, which will request the ADR CHECK PROC / UNRELIABLE SPEED INDICATION to be applied. This function is intended to be introduced in forward fit in 2019 on the A320 Family, and will also be available for retrofit for eligible aircraft (a minimum computers configuration will be required).

The above extracts would seem to indicate that the ATSB identified these significant 'safety issues' long before yesterday?

Keep in mind that if, like most ICAO States with an AAI agency/entity, the ATSB had of issued safety recommendations to Airbus when the safety issues were first identified then Airbus would have been obliged to respond within 90 days - TSI Act reference:

 (2)  The person, association or agency to whom the recommendation is made must give a written response to the ATSB, within 90 days of the report being published, that sets out:

                    (a)  whether the person, association or agency accepts the recommendation (in whole or in part); and

                    (b)  if the person, association or agency accepts the recommendation (in whole or in part)—details of any action that the person, association or agency proposes to take to give effect to the recommendation; and

                    ©  if the person, association or agency does not accept the recommendation (in whole or in part)—the reasons why the person, association or agency does not accept the recommendation (in whole or in part).

            (3)  A person commits an offence if:

                    (a)  the person is someone to whom a recommendation is made in a report published under section 25; and

                    (b)  the person fails to give a written response to the ATSB within 90 days setting out the things required by paragraphs (2)(a), (b) and © (as applicable).

Penalty:  30 penalty units.

 

Ah yes once again the Hooded Canary's mob providing perfect topcover, while Airbus go about the business of patching up/covering up another potential airworthiness grounding - ie 'nothing to see here, all fixed, move along!'  

Now compare that to this from the Ethiopian AAIB:

 

2 INITIAL FINDINGS
On the basis of the initial information gathered during the course of the investigation, the following
facts have been determined:
 The Aircraft possessed a valid certificate of airworthiness;
 The crew obtained the license and qualifications to conduct the flight;
 The takeoff roll appeared normal, including normal values of left and right angle-of-attack
(AOA).
 Shortly after liftoff, the value of the left angle of attack sensor deviated from the right one
and reached 74.5 degrees while the right angle of attack sensor value was 15.3 degrees;
then after; the stick shaker activated and remained active until near the end of the flight.
 After autopilot engagement, there were small amplitude roll oscillations accompanied by
lateral acceleration, rudder oscillations and slight heading changes; these oscillations also
continued after the autopilot disengaged.
 After the autopilot disengaged, the DFDR recorded an automatic aircraft nose down (AND)
trim command four times without pilot’s input. As a result, three motions of the stabilizer
trim were recorded. The FDR data also indicated that the crew utilized the electric manual
trim to counter the automatic AND input.
 The crew performed runaway stabilizer checklist and put the stab trim cutout switch to
cutout position and confirmed that the manual trim operation was not working.

3 SAFETY ACTIONS TAKEN

The day of the accident, the operator decided to suspend operation of B737-8MAX.
On 14th March 2019, Ethiopian Civil Aviation Authority issued NOTAM regarding “The operation of
Boeing B737-8 ‘MAX’ and Boeing B737-9 ‘MAX’ aircraft from, into or over the Ethiopian airspace,
which is still active at the date of this report publication.

4 SAFETY RECOMMENDATIONS

 Since repetitive un-commanded aircraft nose down conditions are noticed in this
preliminary investigation, it is recommended that the aircraft flight control system related
to flight controllability shall be reviewed by the manufacturer.
 Aviation Authorities shall verify that the review of the aircraft flight control system related
to flight controllability has been adequately addressed by the manufacturer before the
release of the aircraft to operations.

Hmm...no further comment required (from me at least)  


However it is guaranteed there will be much MTF...P2  

[Peetwo]

ATSB Estimates: Hooded Canary on a hot tin roof - 

The normally high profile/high viz Hooded Canary has not been sighted for what seems like months...  However yesterday he reappeared in a brief and somewhat subdued session with the RRAT committee in Senate Estimates. The main line of questioning came from sic'em REX on the Angel Flight imbroglio and in particular the Carmody Capers empowered, bollocks instrument...  

Haven't got the Hansard yet but without further ado here is the very interesting session in pictures...  

P2 comment - Hmm...a whistleblower in the midst? I guess it was only a matter of time...

 
MTF? Definitely...P2 

[Peetwo]

Hansard now out: see HERE.

ATSB Estimates: Hooded Canary on a hot tin roof - 

The normally high profile/high viz Hooded Canary has not been sighted for what seems like months...  However yesterday he reappeared in a brief and somewhat subdued session with the RRAT committee in Senate Estimates. The main line of questioning came from sic'em REX on the Angel Flight imbroglio and in particular the Carmody Capers empowered, bollocks instrument...  

Haven't got the Hansard yet but without further ado here is the very interesting session in pictures...  

P2 comment - Hmm...a whistleblower in the midst? I guess it was only a matter of time...

Senator PATRICK: My line of questioning is going to go to the issue of Angel Flight and the instrument that has been tabled in the parliament. I have moved a disallowance which will be decided in the next parliament, but I do want to talk to you about some details because you are in the processes of investigating an Angel Flight that occurred. So that's the context, and I'll put on the record that I have spoken to a number of people involved who have talked to me about various different matters. I'll just also put on the record that, because they're connected to these proceedings and the questions I'm about to ask, I view them as being protected by parliamentary privilege. Some people may have talked to me about—

CHAIR: Hold on. Let's be clear. What are you endeavouring to establish here? You mentioned them.

Senator PATRICK: No, I'm saying I might ask some questions that go to some of the investigations that have been carried out—that they're currently carrying out.

CHAIR: Yes, but why would you need to put them on record? It just sounded like you were bestowing parliamentary privilege—and it may be the case.

Senator PATRICK: I'm just saying I've had conversations with people who have perhaps told me things that they might not otherwise have been able to tell me but for the fact that I'm about to engage in some questions—

CHAIR: Yes, but I'm not sure you should give them the confidence that the parliament—

Senator PATRICK: Okay.

CHAIR: No, Rex; I just don't want to leave it hanging. The words 'parliamentary privilege' were used. I'm not sure it's up to us to bestow that on a whistleblower who's shared information or documents with you. I don't know that it works like that. You might remember we had some in camera whistleblowers recently, and we advise we had was that information at their disposal in a documentary form probably shouldn't have been.

Senator PATRICK: I've taken advice from the Clerk.

CHAIR: Oh, all right. If you want to cite the Clerk into the Hansard, you go ahead.

Mr Hood : Would it help if I outlined where we're at in terms of the investigation?

Senator PATRICK: Yes, you can do that.

Mr Hood : On 28 June 2017, a Tobago aircraft impacted terrain near Mount Gambier, killing all three on board. The ATSB sent an investigation team, and obviously we followed due process since then to investigate the accident and then, of course, to provide the natural justice opportunity to those directly involved in that accident, that being primarily the regulators, the Civil Aviation Safety Authority and Angel Flight to respond to us. We provided an extension to those parties until last Friday. We have received a substantial submission from both parties and, from my perspective, in terms of due process, natural justice, public interest and, of course, the sensitivities of next of kin, the ATSB hasn't traditionally talked about investigations that are currently underway. We think we're about a month to a month and a half away from the final publication of that investigation report.

Senator PATRICK: Sure. My questions are not going to go to the accident itself. I respect that there are good reasons for us not speculating on things. What I want to do, however, is match the instrument that's been tabled against facts that are involved in that particular accident. You'd be aware that an instrument has been tabled that requires 250 hours of in-command time. That is just a simple question of fact. We were told that this instrument was in some sense in response to the previous Angel Flight crash and, indeed, this crash. My understanding is that the pilot in both of those crashes had more than 250 hours. I'm asking you to confirm that. I can actually go through each one of the requirements in here and ask you whether or not it would have had an effect on the previous flight and, indeed, this flight. I'm not actually trying to get to the cause of the accident. I'm trying to focus on whether, if this instrument were in play, it would have made a difference in either Mount Gambier or the previous flight.

Mr Hood : Thank you. The difficulty for us is that, being in the natural justice process, we've done our analysis. We've come up with our draft findings. We're obviously aware of the CASA instrument. We weren't consulted in relation to the CASA instrument, but we're aware of it. And, of course, commenting on the merits of CASA's instrument in a draft report sense in our findings is not complete. As I said, we received substantial input from both Angel Flight and CASA in relation to our draft report. So I think it would be premature for us to comment in relation to CASA's instrument.

Hmm...but maybe someone has already talked out of school?? ref: And - From the Funny Coincidence department.

I fully support - minimum pilot experience and currency - minimum licensing requirements - minimum Class1 medical - all night flight to be using instrument procedures - aircraft maintenance to charter standards. The general public has not enough knowledge to make the call. The emotions involved lead pilots to make hasty and not always good decisions about their capabilities. I know everyone wants to help and be seen a hero but no-one wants their nearest and dearest to end up in a crumpled heap of metal in cumulogranite. The PATS scheme whilst less glamorous is adequate for most people's transport. A little extra input from doctors into the application assists in ensuring the patient gets transport appropriate to their condition.

https://consultation.casa.gov.au/regulat...=842062909

..Mr Hood : In our draft report we've looked at both what happened and why, in terms of the Angel Flight accident at Mount Gambier. Consistent with looking at the why we've obviously looked at the operator, as we have the regulator as well. The other point to make is we're completely independent of CASA in this matter. Our report has been developed in complete isolation of any action that CASA may have chosen to take in relation to that instrument. 

Senator PATRICK:Sure. But if you're intending to make some adverse finding in relation to Angel Flight and perhaps suggesting that their pilots are under pressure, for example—because Mr Carmody indicated to us that their pilots are under a particular pressure because of the nature of these flights. My understanding is your draft report effectively says that, but it's not grounded by evidence. You haven't gone to a whole range of different Angel Flight pilots and talked to them about any pressures they might have...

Hmm...no comment required, I'll leave that to the experts....  


MTF...P2 

[P7_TOM]

Hood – Should, Could and did not. Why?????????

O’Sofullofit; fails, utterly (as usual) by stepping around the glaring, basic issues. Perhaps he should take a slightly broader view, in particular, the complete disregard CASA have continually demonstrated in relation the ‘safety recommendations’ offered by ATSB. It is quite a history and those who are not totally across the subject matter should spend a little time getting familiar. I know P2 is delving deeply into various matters in an attempt to discern why CASA have thrown up a huge smoke screen, using AF as their whipping boy to excuse their past dismissal of ATSB (pre Hood) and Coroner recommendations as suggestions only. Despite O’Sofullofit’ continual, fatuous, repetitive claims to ‘understanding’ , experience and being full bottle on ‘investigations’ I say he needs to STDU and do his homework, rather than keep telling us what a whizz-bang safety guru he is. He ain’t – he’s either a very naughty boy; or, we need to question his ‘motivation’.  

For example – this accident report – HERE – is important. It was crewed by ‘commercial pilots’ operating under a CASA ‘accepted’ system, duly licenced to conduct commercial operations in well maintained aircraft. Two ‘qualified’ pilots – overwhelmed and confounded by pretty standard conditions for the NT, in an aircraft type which has been a stalwart veteran of NT operations. Why has CASA not upped the ante on this little performance; starting with ‘statistics’ and under laying cause and effect?

The AF debacle is a smoke screen; Essendon was an important event; Ross Air was an important event; the Braz was an important event; the Coal Loader event at Newcastle was an important event; the Virgin / Qantas episode was an important event; the ATR was an important event; the Swan river crash was an important event – must I go on? WTD are we wasting time, money and effort on here; Angel Flight deaths? It’s a total Bollocks. Safety as ‘we’ (the industry) have understood it – operationally – is going to Hell in a hand cart – CASA is driving – Hood is pushing and the Devil is working the whip. Will someone , anyone please put the brakes on this lunacy.

Something in Denmark stinks to the high heavens;

No – no thank you dear heart – I’ll walk home now; fresh air and quiet needed more than one for the road. Ale and disgust is not a happy mix.

[Peetwo]

O&O report AO-2016-166

The following is an Oz Aviation summary article of this - AO-2016-166 - ATSB FR released three days ago   

ATSB calls for centreline lighting on wider runways after 2016 incident

written by australianaviation.com.au May 15, 2019

The impact of the Virgin Australia runway excursion at Darwin Airport. (ATSB)

The Australian Transport Safety Bureau (ATSB) is renewing calls for centreline lighting to be installed on wider than usual runways following a 2016 incident where a Virgin Australia flight destroyed six runway lights when it landed 21m off the centre of the runway.

The incident occurred on December 6 2016, when the Virgin Australia Boeing 737-800 VH-VUI flying from Melbourne to Darwin was on approach to Runway 29. There was thunderstorm activity in the area and the flight was due to land at about 2300 local time.

The ATSB final report into the incident published on Wednesday said the flight crew had established and maintained clear visual reference to the runway and surrounds “until they encountered heavy rain shortly before reaching the runway threshold”.

“Under the influence of a light but increasing crosswind, the aircraft drifted right without the flight crew being able to discern the extent of the drift,” the final report said.

“The aircraft landed 21m to the right of the runway centreline and, shortly after touchdown, the right landing gear departed the sealed surface of the runway, destroying six runway lights before the aircraft returned to the runway.

“The aircraft incurred minor damage from ground debris and there were no injuries.”

In addition to the six runway lights being destroyed, the ATSB final report said debris from the lights and ground impacted the aircraft, resulting in minor damage to areas of the right aft fuselage and right horizontal stabiliser, and littered the edge of the runway surface.
There was also a large quantity of grass accumulated in the vicinity of the right wheel well, landing gear and wing flaps.


Wheel tracks where VH-VUI departed the runway 29 sealed surface and destroyed runway edge lights. (ATSB)


The tyre damage on VH-VUI. (ATSB)


The fuselage damage, marked with green tape, on VH-VUI. (ATSB)

Runway 29 at Darwin Airport measures about 60m wide and 3,350m long. The ATSB report noted the runway was about 15m wider than “almost all the other runways used by air transport aircraft in Australia”. It does not have centreline lighting.

As a result, the ATSB said the two rows of lights alongside Runway 29 were further apart than what a flight crew would normally encounter.
The ATSB said the absence of centreline lighting meant there were “very limited visual cues for maintaining runway alignment during night landings in reduced visibility”.

Darwin Airport is a shared civil and military facility. The Department of Defence owns the runway and other airport infrastructure, while Darwin International Airport runs the civilian operation.

The ATSB noted that while international guidelines recommended the use of centreline lighting on wider runways, there was no mandate from the International Civil Aviation Organisation (ICAO) to do so.


The final approach and landing roll of VH-VUI. (ATSB)

Further, its accident investigation records from 1997 to 2007 showed there had been two other incidents at Darwin Airport where the absence of centreline lighting may have been a factor.

The first was in 2003, when the right landing gear of a Boeing 737 veered off Runway 29 after landing 590m from the threshold, followed by the left landing gear about 760m from the threshold.

Another occurred in 2008, when a Boeing 717 made a “hard landing” at night. The ATSB investigation at the time said the lack of runway centreline lighting had reduced the available visual cues during the latter stages of the approach and landing on Runway 29.

The ATSB had recommended the installation of centreline lighting at Darwin Airport following the 2003 incident.

However, Darwin International Airport responded at the time that “a standard runway centerline system would be prohibitively expensive and is not currently a standard for our runway category”.

The ATSB also raised concerns following the 2008 landing. While the ATSB did not issue recommendation, it did seek a response from the Department of Defence, which said the installation, upgrade and maintenance costs for centreline lighting did not represent value for money.

“A wide runway without centreline lighting, such as at Darwin, poses a particular challenge for aircraft making approaches in darkness and heavy rain,” ATSB executive director for transport safety Nat Nagy said in a statement.

“In these circumstances centreline lighting greatly helps flight crews align the aircraft with the runway.”

The ATSB has issued a safety recommendation to ICAO to review the runway lighting standards in light of the new evidence available.

“The Australian Transport Safety Bureau recommends that the International Civil Aviation Organization review the effectiveness of Annex 14, recommendation 5.3.12.2 (for the installation of runway centreline lighting on Category I runways that are wider than 50 m), given that Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions,” the ATSB said.

The ATSB said both Darwin Airport and the Department of Defence had advised it that the installation of centreline lighting would be considered during any future runway works.

Meanwhile, the ATSB final report said Virgin Australia had introduced additional guidance to flight crews for approach to Darwin airport, including notes about runway surface, slope, width, lighting, and ambient light.

The carrier had also initiated specific training to pilots for loss of visibility in heavy rain, investigated enhancements to simulator modelling of degraded visibility at low levels, reviewed risk profiles for each airport including Darwin, commenced a program to investigate the potential to install hydrophobic windshield coatings on its 737 fleet, initiated a review of callouts for loss of visibility and reviewed the use of autopilot in poor weather, the ATSB said.

The full report can be read on the ATSB website.

On the face of it the report seems reasonable, however once you start to dissect, push, probe and compare IMO this is just another in a long..long series of top cover reports by the Hooded Canary and his not so merry team...

To begin why on earth did this investigation take 2 years, 5 months and 10 days (or 616 working days) to complete?

According to the safety issue addressed to Virgin the airline's SMS team had their identified safety issue(s) addressed inside of 2 months:

Aviation safety issues and actions
Operator guidance to flight crews
Issue number: AO-2016-166-SI-03
Who it affects: Virgin Australia Airlines flight crews operating into Darwin airport
Issue owner: Virgin Australia Airlines
Operation affected: Aviation: Air transport
Background: Investigation Report AO-2016-166
Date: 15 May 2019
Safety issue description
Virgin Australia did not have formal guidance for flight crews regarding the limited visual cues for maintaining alignment to runway 11/29 at Darwin during night landings in reduced visibility.

Proactive Action
Action organisation: Virgin Australia Airlines
Action number: AO-2016-166-NSA-012
Date: 20 January 2018
Action status: Closed
On 20 January 2017, the operator introduced additional guidance to flight crews for approach to Darwin airport, including notes about runway surface, slope, width, lighting, and ambient light.

Current issue status: Adequately addressed
Status justification:
The operator’s action, in conjunction with other safety actions, should provide crews with adequate guidance to enable them to assess risk and prepare for approaches in low visibility conditions at Darwin Airport.


Last update 15 May 2019

One has to ask how is it possible for an ATSB identified safety issue (above) be proactively addressed by the addressee a year before the safety issue was identified? And why wasn't the safety issue once identified then disseminated across the international aviation/airline industry? Surely if this was a deficiency in one airline this could also have a been a deficiency in other airlines?

Extract from the ATSB report:

Runway design standards and guidance

The International Civil Aviation Organization (ICAO) specifies standards and recommended practices (SARPS) for international aviation operations in a series of Annexes. ICAO Annex 14 (Aerodromes, Volume 1 Aerodrome Design and Operations, 7th edition July 2016) stated that runway centreline lights and touchdown zone lights shall be provided for runways with a category II or III[19] precision approach. It also stated:

5.3.12.2 Recommendation— Runway centre line lights should be provided on a precision approach runway category I, particularly when the runway is used by aircraft with high landing speeds or where the width between the runway edge lights is greater than 50 m.

Annex 14 had included the same or similar recommendation since 1966. There was no recommendation for touchdown zone lights for category I runways.

ICAO also published other guidance about aerodrome lighting. For example, ICAO document 9157 (Aerodrome Design Manual, Part 4 Visual Aids) stated:

The function of the centre line lighting is to provide the pilot with lateral guidance during the flare and landing ground roll or during a take-off. In normal circumstances, a pilot can maintain the track of the aircraft within approximately 1 to 2 m of the runway centre line with the aid of this lighting cue. The guidance information from the centreline is more sensitive than that provided from the pilot’s assessment of the degree of asymmetry between the runway edge lighting. In low visibility conditions, the use of the centre line is also the best means of providing an adequate segment of lighting for the pilot to use. The greater distances involved in viewing the runway edge lighting together with the need for the pilot to look immediately ahead of the aircraft during the ground roll also contribute to the requirements for a well-lit runway centre line.

Another section of the manual stated:

…Some of the most difficult tasks when flying an aircraft visually are judging the approach to a runway and the subsequent landing manoeuvre. During the approach, not only must the speed be carefully controlled, but continuous simultaneous corrections in all three dimensions are necessary in order to follow the correct flight path.


…There are two reasons why approach and runway lighting systems are provided with patterns that emphasize the centre line. One obvious reason is that the ideal landing position is along the centre of the runway. The other is that the fovea of the eye, the region of sharp vision, is only about 1.5 degrees in width…

Studies have shown that the average time required for a pilot to switch from outside visual cues to instruments and back to outside cues is about 2.5 seconds. Since high performance aircraft will travel at least 150 m in this time period, it is apparent that in so far as possible the visual aids should provide the utmost in guidance and information, enabling the pilot to proceed without the necessity of cross-checking the instruments…

Consistent with Annex 14, the MOS for CASR Part 139 required centreline and touchdown zone lighting for runways with category II or II approaches and recommended centreline lighting for category I runways with a width of more than 50 m.

Next from under 'other factors that increase risk' the ATSB report addressed a SR to ICAO:

Standards for installation of runway centreline lighting on wider runways 

Safety issue number:  AO-2016-166-SI-01
Safety issue: Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions. The installation of centreline lighting on wider category I runways is recommended but not mandated by the International Civil Aviation Organization Annex 14.

Safety recommendation to the International Civil Aviation Organization

The Australian Transport Safety Bureau recommends that the International Civil Aviation Organization review the effectiveness of Annex 14, recommendation 5.3.12.2 (for the installation of runway centreline lighting on Category I runways that are wider than 50 m), given that Category I runways that are wider than 50 m and without centreline lighting are over-represented in veer-off occurrences involving transport category aircraft landing in low visibility conditions.

"..recommended but not mandated.." - Hmm...I thought everyone knew that ICAO only 'recommends'? After all the ICAO Annexes (SARPs) are exactly 'Standards And Recommended Practices' and a country which wishes to have a difference to those SARPs simply notifies that difference. Mandating is something the ICAO doesn't have the power to do but mandating is something that a signatory State's NAA (National Aviation Authority) is ultimately responsible for. This begs the question to why it is that the Hooded Canary team have not addressed a similar SR to CASA?

...Consistent with Annex 14, the MOS for CASR Part 139 required centreline and touchdown zone lighting for runways with category II or III approaches and recommended centreline lighting for category I runways with a width of more than 50 m...

Hmm...MTF? - Definitely...P2  

ps Although there is no notified difference from Australia for Annex 14 Ch 5 para 5.3.12.2 there is one for 5.3.12.3 which is listed as a rare 'More exacting or exceeds' ND:

Runway centreline lights must be provided on the following: (a) a Cat II or III precision approach runway; (b) a runway intended for take-offs with an operating minimum below an RVR of 350 m.

 
Hmm...as usual 'nothing to see here, move along' - 

[Peetwo]

Twenty five years; four tails; 478 funerals; a birdstrike; and a broken leg - Part I     

When you Google "longest aviation accident investigation ever" the top of the page comes up with this NTSB link:

NTSB Concludes Longest Investigation in History; Finds Rudder Reversal was Likely Cause of USAIR Flight 427, A Boeing 737, Near Pittsburgh in 1994. ... Theflight was arriving from Chicago. All 132 persons aboard - 127 passengers and 5 crew - perished in the crash.

https://www.ntsb.gov/news/press-releases...737_N.aspx

Now I am not sure if with the publishing of the final investigation report into US Air flight 427 on the 24 March 1999, if the NTSB actually holds the world record for the longest completed AAI but yesterday the 4 year 6 month 17 day investigation was well and truly pipped (5 years 3 months 5 days i.e. 261 days) by our very own Hooded Canary led ATSB with the release of the FR into the 20 February 2014 broken tail ATR accident...   

This is the ATSB presser:

ATSB issues recommendations for improved aircraft design tolerance to inadvertent dual control inputs
The Australian Transport Safety Bureau has issued Safety Recommendations to the European Aviation Safety Agency (EASA) and aircraft manufacturer ATR seeking improved aircraft system design tolerance to inadvertent dual control inputs by pilots.



The Safety Recommendations are contained in the ATSB’s final investigation report into an inflight upset and inadvertent pitch disconnect experienced by an ATR 72 turboprop airliner on a flight from Canberra to Sydney in 2014.

During that flight, as a result of a sudden decrease in tailwind, the ATR’s pilots unintentionally applied opposing control inputs to their control columns while trying to ensure the aircraft remained below its maximum operating speed. These differential forces activated the aircraft’s pitch uncoupling mechanism. Intended for activation in the event of one of the aircraft elevators being jammed, the pitch uncoupling mechanism resulted in a pitch disconnect, where the elevators could operate independently of each other.

With the pilots applying opposing control inputs and built-up tension within the flight control system, the pitch disconnect resulted in transient asymmetric elevator deflections, generating aerodynamic loads that exceeded the strength of the horizontal stabiliser (tailplane), causing significant damage.

The aircraft landed safely and was inspected by maintenance engineers but the damage was not detected. The aircraft returned to service and operated a further 13 flights before a subsequent inspection after a suspected birdstrike found it had sustained serious structural damage to its horizontal stabiliser, which was subsequently replaced.

Discovery of that damage was the catalyst for one of the ATSB’s most complex, thorough and protracted safety investigations.

Through the release of two interim reports, the investigation has already seen the aircraft manufacturer, aircraft operator and aircraft maintenance provider address a number of safety issues identified by the ATSB.

However, as part of its final report, the ATSB has issued a Safety Recommendation to EASA, recommending taking “further action to review the current design standard (CS-25) in consideration of effect that dual control inputs may have on control of aircraft.”

In addition, the ATSB has issued two Safety Recommendations to aircraft manufacturer ATR, recommending that ATR:

• assess the operational risk associated with limited tactile feedback between left and right control columns in the context of no visual or auditory systems to indicate dual control inputs; and
  
• perform a detailed review of the effects of dual control inputs on the aircraft’s longitudinal handling qualities and control dynamics to determine if there are any detrimental effects that could lead to difficulty in controlling the aircraft throughout the approved flight envelope and operational range.
  

“What this report seeks to achieve is to influence further incremental safety improvements,” ATSB Chief Commissioner Greg Hood said.

Aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent flight crew actions.

“This serious incident demonstrates aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions.

“Further, when identified, aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.”  

Mr Hood said the investigation also highlights the importance of a full and proper inspection to detect aircraft damage and the need for the inspection to be fit for purpose and for inspections to be coordinated and certified to avoid a single point failure.
“The ATSB looks forward to EASA’s and ATR’s responses to our Safety Recommendation from this investigation.”

Read the report AO-2014-032: In-flight pitch disconnect involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014
 SHARE THIS PAGE  FEEDBACK
Last update 24 May 2019

Spot the disconnects (pun intended -   )??

Perhaps this will help?

Via FR:

Based on the crew report of an in-flight pitch disconnect associated with moderate turbulence, and data recorded by the aircraft’s on board maintenance systems, VARA maintenance watch arranged for the contracted approved maintenance organisation, Toll Aviation Engineering, to carry out the applicable maintenance. However, the licenced aircraft maintenance engineers involved in the Inspection after flight in turbulence and/or exceeding VMO did not carry out the specified general visual inspection of the stabilisers probably because of a breakdown in the coordination and certification of the inspection tasks between the engineers. The damaged horizontal stabiliser was not detected and the aircraft was released to service...

VH-FVR under tow following completion of post-occurrence maintenance. The angle of the horizontal stabiliser relative to the angle of the wings indicates substantial structural deformation.


Source: Sydney Airport

During the next 5 days the aircraft was operated on 13 flights and was subject to routine walk‑around visual inspections by flight crew and engineers. No one identified any anomalies until flight crew observed some damage after a suspected bird strike. The aircraft was grounded and subjected to extensive maintenance that included replacement of the horizontal and vertical stabilisers.

Upper tailplane of VH-FVR showing damage to horizontal and vertical stabilisers that was evident when the damage was identified 5 days and 13 flights after the in-flight upset/pitch disconnect and associated maintenance

Note that the Hooded Canary indicates that both ATR and EASA were issued with the same SR. What he neglects to say is that same SR was also issued to CASA:

Consideration of transient elevator deflections from a pitch disconnect 
Safety issue number: AO-2014-032-SI-02
Safety issue description: The aircraft manufacturer did not account for the transient elevator deflections that occur as a result of the system flexibility and control column input during a pitch disconnect event at all speeds within the flight envelope. As such, there is no assurance that the aircraft has sufficient strength to withstand the loads resulting from a pitch disconnect.

Safety recommendation to ATR
The ATSB recommends that ATR complete the assessment of transient elevator deflections associated with a pitch disconnect as soon as possible to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that ATR take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.

Safety recommendation to the European Aviation Safety Agency
The ATSB recommends that EASA monitor and review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that EASA take immediate action to ensure the ongoing safe operation of ATR42/72 aircraft.

Safety recommendation to the Civil Aviation Safety Authority
The ATSB recommends that CASA review ATR’s engineering assessment of transient elevator deflections associated with a pitch disconnect, to determine whether the aircraft can safely withstand the loads resulting from a pitch disconnect within the entire operational envelope. In the event that the analysis identifies that the aircraft does not have sufficient strength, it is further recommended that CASA take immediate action to ensure the ongoing safe operation of Australian‑registered ATR42/72 aircraft.

 
This is part of the weasel worded response to that SR from CASA:

...CASA advised that since 10 February 2016, they have been involved in a comprehensive dialogue with ATR and EASA regarding the assessment of the transient elevator deflections associated with pitch disconnect to address this safety recommendation. CASA has also engaged with the ATSB throughout the investigation. CASA provided an interim response to the ATSB safety recommendation on 15 June 17. CASA intends to provide a further response to the ATSB safety recommendation following the release of the final report. That response, in part, depends on EASA’s response to the same safety recommendation...

Remember again that this accident occurred 1921 days ago - 

TBC...P2 

[thorn bird]

"That response, in part, depends on EASA’s response to the same safety recommendation..."

There you go P2....Why are you surprised CAsA would do anything off its own bat.

If they preempted anyone else they would own it. Whats rule 101 of CAsA? NO LIABILITY to hell with safety.

Choc frog Thorny -   P2

[P7_TOM]

There you go – how many pilots, check and training experts, not to mention trained investigators do you think will believe that load of disgraceful TWADDLE.

“During that flight, as a result of a sudden decrease in tailwind, the ATR’s pilots unintentionally applied opposing control inputs to their control columns while trying to ensure the aircraft remained below its maximum operating speed.” BOLLOCKS.

“This serious incident demonstrates aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions.” WTF - BOLLOCKS.

Think about that statement for a moment. ‘Inadvertently’ one bloke thinks the nose should come Up – the other reckons Down is the way to go (‘cos of the ‘sudden decrease in ‘Tailwind’ – Bwaa HaHa) then there is an arm wrestling competition which separates the elevator channels. WTF was going on in that cockpit and who was flying the aircraft – certainly not a qualified disciplined crew of pilots - . Yet ATR must redesign a perfectly good system on Hood's say so. Un- duckling -believable.



On safety grounds alone Hood’s resignation should be called for; the time, the money and the BOLLOCKS in this report demand it.

Disgraceful.

[Kharon]

AO -2014 – 032. Adding  insult to inujry.

When Dolan invented the ‘Beyond Reason’ method of accident investigation, I think most understood that it was a load of old cobblers – designed to throw the Senate investigation into the Pel-Air shambles off the scent. I doubt there was even a professional airman, let alone a qualified accident investigator who believed a word of it. We all expected that would be last time this chimera raised its ugly, misbegotten head. Wrong: not only has Hood adopted it, but has actually set about installing it as the new ‘norm’. “Bullshit” howls the mob. “Unbelievable is it – read this” is the reply. Shocked silence follows the reading.

Which is about where I am – slightly shocked and bordering on furious having read through this ‘thing’ called a ‘report’. For a start I wonder how could this event could ever have taken place. Seriously; it should never have occurred. But it did and we need to examine why it did, there are some serious, deadly serious safety implications being ignored; written out of the script by ATSB. AP has a team working on this puerile ATSB disgrace as we speak; and, that analysis of this report (soup to nuts) will be made as public as is within our reach. For an entrée, let’s take an overview.

There are many ATR aircraft floating about this planet; it is a success story; a tough, dependable, work horse which earns it’s keep and generates profits for the operators. Every aircraft type, since the Wright brothers kicked off has ‘niggles’ and ‘stuff’ which give the aircraft its ‘character’. The ATR is a turbo prop and operates best where jet aircraft are impractical, this often means ‘tough’ environments; all the bells and whistles; storms, ice, wind shear; fog, adverse winds, short runways, mountains and their tricky winds, islands and their unique conditions etc. Routine stuff – part of a flying life. The ATR not only survive in this, but thrive in it. Not too many instances of elevator channel disconnect mentioned – despite hard work in tough ports is there. Yet here we have a serviceable aircraft busted in relatively benign conditions, in clear sky, in daylight en-route to a major aerodrome, because – Why?

The next element is why the aircraft was not only returned to service after the event; but allowed to continue operating. Which begs other questions related to inspection pre flight.

AP will begin at the beginning – Human Factors. Company ethos and the subliminal pressures placed on flight crew. For example – OTP and slot times. OTP (On Time Performance) is a management toy – a thing of advertisement and bonus; which has SDA to do with flight crew. Then we have Flight and Duty times which, once again, have SDA to do with crew. Yet these elements impact on the crew. Where this leads is to the ‘push to rush’. When you factor in the ‘macho’ thing – there is a good case supporting high speed descent. Red line at 250 KIAS – descent at 250 KIAS - . Not prudent. Item next – computers; despite the rumours, do not have a brain – they can’t think; let alone see and read the sky. The Auto pilot simply does as asked – without being obliged to anticipate anything. Add to this a crew which completely disregarded not only the ‘clues’ but SOP and common sense and you end up with a busted aircraft; and terrifyingly  – a series of flights, each of  which could have ended in disaster. ATR reliability and inherent ‘toughness’ demonstrated - yet again. Not only did it get the passengers safe home – but went on to do again and again without failing: i.e. the tail remained attached to the airframe.

It is reasonable to question one other element before you begin to take this episode apart – operating policy. For some reason the nominal height of 400 feet has become fixed in the mind of operators – at 400’ the Auto Pilot must takes over flying duties. Two things very wrong with this. (1) 400’ is not always the Obstacle Clearance Height (OCH) for the weight/ temperature/ flight path; (2) the AP will simply correct for an out of whack control surface. IMO a pilot worth the name would; if actually flying the aircraft, pick up ‘something’ wrong with the arse end and report it – next landing. (Gods willing - weather permitting). Selah.

This much delayed, obfuscated report into the ATR is, IMO an insidious danger to navigation. Hood should resign and the report redrafted to correct the glaring obscenities contained. Will the real investigators please speak up – before it’s too late and the acronym ATSB becomes an international disgrace.

Toot – toot.

[Peetwo]

Reference 26/05/19 SBG: https://auntypru.com/dont-get-in-our-way/

Twenty five years; four tails; 478 funerals; a birdstrike; and a broken leg - Part II

Ref P9 post:

...This much delayed, obfuscated report into the ATR is, IMO an insidious danger to navigation (P2 - not just your opinion P9) . Hood should resign and the report redrafted to correct the glaring obscenities contained. Will the real investigators please speak up – before it’s too late and the acronym ATSB becomes an international disgrace... P2 - Way, way...too late for that, much like the 2nd iteration of the PelAir cover-up report and the serious cover-up of the MH370 search, this one has all the pugmarks of a Chief Commissioner well prepared to take it up the ----?     

A couple of additional points of interest with this absolute WOFTAM, useless, diabolical, morally bankrupt, insanely disconnected from reality, Hooded Canary report...

On top of coincidentally releasing this report while Australia is in a Governmental and political vacuum, this internationally associated (ATR & EASA) ATSB final report and accompanying presser just so happened to be released on the same day that the entire international aviation safety community and the most influential NAA's (national aviation authorities) were otherwise preoccupied with the Boeing 737 MAX saga - see HERE. 

Coincidence maybe but from a Hooded Canary topcover point of view it has had the desired effect with only one media publication (i.e Australian Aviation) daring to draw attention to this latest ATSB cover up report. 

Now although the potential on-board fatalities of the 20 February 2014 VARA ATR-72 flight from YSCB to YSSY could never match the total on-board fatalities - (478) of the tragic flights of US Air 427, Lion Air 610, Ethiopian Airlines 302 - there was still a latent potential for there to be a lot more fatalities than the total 70 odd capacity of the aircraft that flew for an additional five days and 13 sectors after the accident occurred. 

Regardless of the robustness of the ATR turbo-prop fleet Australia again (like with the Mildura fog cock-up and other examples) definitely dodged a bullet -   

Dear Miniscule for GOD's sake WTF UP!

MTF...P2