[Peetwo]

Dr Godlike's bollocks summary of VA ATR double-flameout investigation -   

While the BRB continues to review the Australian Top Cover Bureau's latest PC'd report on the tragic Rossair C441 Renmark accident (see HERE), I note that yesterday there was yet another bollocks Dr G media release which accompanied the completion of the AO-2018-081 AAI involving a VA ATR-72 double flameout on approach into Canberra on the 13 December 2018 -   :

 Investigation finds engine automatic ignition system worked as designed, highlights appropriate use of selecting manual ignition


A turboprop airliner’s automatic ignition systems performed as designed, successfully relighting the aircraft’s engines after they separately flamed out in heavy rainfall when the aircraft was on descent to land at Canberra Airport, an ATSB investigation has found.

The Virgin Australia ATR72-212A (ATR72-600), registered VH-FVN, was operating a scheduled passenger flight from Sydney to Canberra on 13 December 2018. Due to thunderstorm activity, the pilots were cleared by air traffic control to divert left of their planned track and subsequently held to the south-east of Canberra before tracking south then west to fly around the weather and then tracking back to land.

Shortly after commencing the descent into Canberra, passing 11,000 feet in heavy rain, the aircraft’s right engine flamed out*. The engine’s automatic ignition system engaged and the engine relighted within five seconds without pilot input. Then, approximately one minute later, passing 10,000 feet, the left engine flamed out and it too automatically recovered within five seconds, again without pilot input.

The ATR72’s automatic ignition system worked as designed, correctly detecting the loss of engine power, initiating ignition and successfully relighting the engines without pilot input.

The incident highlights that while engine flameouts are not common in modern turboprop aircraft, they are still possible, according to ATSB Director Transport Safety Dr Stuart Godley.

“The ATR72’s automatic ignition system worked as designed, correctly detecting the loss of engine power, initiating ignition and successfully relighting the engines without pilot input,” Dr Godley said.

After the second engine flameout, the captain selected engine ignition to ‘manual’ in order to provide continuous ignition in an attempt to prevent any further flameouts.

“However, the selection of manual ignition potentially reduces the effectiveness of flameout recoveries, and should only be used when directed by checklists or a minimum equipment lists,” Dr Godley said.

The ATR72’s Pratt & Whitney Canada PW127M engines have a high-energy ignition system which is automatically disengaged following engine start, but in the event of a flameout, will automatically deliver a spark rate of between five and six sparks per second for 25 seconds before reducing to once per second until the engine relights.

Selecting manual ignition would also deliver an initial spark rate of between five and six sparks per second for 25 seconds before reducing to once per second. Consequently, if manual ignition has been ON for more than 25 seconds at the time of a flameout, it would not provide the high initial spark rate of automatic ignition, potentially delaying the relight process.

“This investigation highlights that reliable and effective systems and procedures exist to protect and recover from flameouts and it is important that pilots follow manufacturer procedures,” Dr Godley said.

The investigation noted that ATR’s Flight Crew Operating Manual did not prohibit the use of manual ignition in situations other than where the Electronic Engine Control unit was malfunctioning, and had no explicit direction for ignition to remain set to automatic.

Since the incident, ATR has ensured all operators of the ATR72-600 are aware of the appropriate use of the manual ignition, and is also reviewing operational documentation to determine whether this requirement could be explicitly included.

* A flameout is an unintentional extinguishing of the flame in the engine. This may result from interruption of any of the requirements for sustaining combustion, being fuel, air and heat.

Read the investigation report  AO-2018-081: Engine Flameouts on descent involving ATR72, VH-FVN, near Canberra Airport, ACT, on 13 December 2018

Hmm...incoming?? 

MTF...P2 

[Kharon]

Nah – No way will I even give more than a short, sharp, Duck off to the Godley pronouncements; as if he would have the first blind clue. Cheap, shifty, shitty operators elect for the standard version. Real operators pay for the up grade which allows for 'continuous' as and when required. I'd like to see his face with a double failure for the last minutes of final approach on a wet, windy, bumpy, pissing down pick handles night; ice, rain, wind, minima and visibility marginal at best - no worries there then? Microsoft Flight Simulator at home, don't quite reflect the reality of maintaining a 'stable' approach. One out then on, then the other – then both; then none, then one but not the other. BOLLOCKS – Nah – no thank you - been there done that, (twice). Just wish that all Bloody pen pushing, pencil neck fools would stay at home and play with pretty little graphs, take up knitting or whatever.

[Peetwo]

Old Akro once again nails it on the UP -   

Previous thread reference:

Hooded Canary releases Mangalore mid-air prelim report - 

Via HC central yesterday:

Warning: Bucket may be required for the Hooded Canary segments -   

Read the preliminary report AO-2020-012: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel Air, VH-AEM, near Mangalore, Victoria, on 19 February 2020

Not sure exactly why the Hooded Canary feels the need to put his 2 bob's worth in? Why can't he just leave it to his experts? Perhaps HC is just trying to justify his existence and bloated (nearly 500k) base salary but I do wonder if there isn't some hidden (singing Canary) message behind this?

For a more damning assessment of the ATSB's findings so far IMO you can't go past the 'Advance' post off the UP -   

OA via the UP: https://www.pprune.org/pacific-general-a...st10795136

Old Akro

But it can be reduced. That's why pilots participate in cyclic check and training, flight reviews etc. It's why we have developed checklists and crosschecking etc. All these came through studies and and research leading to redesigning of systems based around human factors. It's the basis for why T.E.M is now a mandatory competency for pilots. 

Tell that to the Renmark pilots operating a periodic review under supervision of a CASA FOI.

James Reason himself details the limits of process based safety in his books. In many ways Tony Kerns work takes over from James Reason. But personal responsibility doesn't fit well with a regulators mind set.

This forum is good at being unforgiving of pilots. But this accident had 4 very well qualified pilots with very good recency flying well equipped aircraft. Both had active IFR flight plans. Both were flying consistent with their flight plans. Personally, I cannot point to anything that would give me any comfort that the same thing would not have happened to me.

The ATSB report acknowledges that both aircraft were identified via ADS-B returns received by the AsA system (as opposed for F24 etc). The ATSB preliminary report acknowledges that the AsA system had the information that indicated a traffic conflict (note that I say system, not controller. Its unknown what the controller was presented). ATSB have departed from typical practice by not making any comment on the recorded radio transmissions in its preliminary report, nor presenting any transcripts. Which is curious.

This is going to be a complex report and I'll put money on the ATSB not publishing a final report for 3 years after the accident. But I'm pretty sure that airspace design (ie class E, CTAF and control step location), radio frequency boundaries, radio procedures and the concept of aircraft self separating in IMC are all likely to feature in the final report. These are all systems based issues.

And comments in reply:

Squawk7700

ATSB have departed from typical practice by not making any comment on the recorded radio transmissions in its preliminary report, nor presenting any transcripts. Which is curious.

This says a lot about what might be coming later.

Stickshift3000

I'll put money on the ATSB not publishing a final report for 3 years after the accident.

No takers here, that's a sure thing.

[Kharon]

'Roll Up, roll up:

For an autographed, Hi-Viz jock strap with 'Courage' embroidered on the pocket – answer 10 bloody fool questions to win a personal 'fitting up' (touch up extra).

“Why?” - Asks the slightly bemused crowd.

Well boys and girls – the WWWW from WW is having to answer some pretty awkward questions. He's been neck deep in Shitter's Ditch since the almost unbelievable debacle of Angel Flight ('cept it was believable) then there's the SOAR/RA Oz bun fight all being looked at by a Senate Committee. So – given the ATSB skills with 'statistics' a survey is a cunning plan. Making numbers jump through hoops is an ATSB party trick; the 'statistical facts' from your wasting 10 minutes responding will reflect a glowing industry report of 'delight' in the Hooded Canary's version of investigative probity and analytical clarity – not to mention the great safety ideas generated after every event.

Take heart and bathe in the reflected glory of the Ross Air, Air North, Virgin ATR saga, Mangalore, Essendon DFO  to mention but a few of the 80 odd reports reviewed for no constructive result.

Perhaps Hoody's wardrobe mistress could find three golden parachutes; one for each of the top dogs at ATSB and help them to the exit with the Industry approved S10 B method of persuasion. (S10B – Size 10 Boot works like a charm).


1. Please identify the transport sector(s) you are primarily involved with or interested in:

No – I am an aviator and rely on a broad range of information, from all sectors to keep me  informed.

2. Which best describes your employer / employment situation in relation to your interest or involvement with the ATSB?

Now why would you need to know that? I belong to a diverse industry, have held positions in all manner of operations and depend on current, valid safety reports to update my approach to safety.


3. How would you rate your overall knowledge of the ATSB?

Extensive – down to the last outfit in the company wardrobe.


4. How well do you recall ATSB safety messaging relevant to your industry over the past 12 months?

What bloody safety messages. There's a lot of arse covering information – but sweet bugger all of value to a working airman.

5. Where have you received or sourced information from the ATSB over the past 12 months? (Select multiple if required)

Someone usually finds the odd three year in the making report and puts on social media –just for the laughs you understand. We like the pictures of Hood looking wind-swept and interesting best. The MH 370 crowd use the soft print version for personal hygiene. Great value....


6. How would you rate the technical standards of ATSB investigation reports?

Stellar – for pure simplicity. E.g. Two aircraft banged together in cloud, crashed and burned, killing four. What more need to be said? Why bother ASA and upset the million dollar Halfwit with unsettling questions like 'how in the seven hell's did this happen'? Or God's forbid some sort of rational airspace system be brought on line. Or, question the ADSB impost and ask why Halfwit's One big Pie is already out of date, late and not worth a Tinker's cuss. Yep; outstanding, the NTSB must be beating down the doors to gain this level of 'technical excellence'.

7. How would you rate the credibility and relevance of ATSB investigation reports?

Well, good question. The tea lady actually can read the tea leafs, my Grand Mamma is a whizz with the old Tarot pack and Uncle Jack's trick knee is always bang-on when it come to fishing. ATSB credibility pales in comparison; and, for relevance, I always ask the hanger cat's opinion. So the complete lack of ATSB credibility or indeed relevance is a nugatory question in the face of such sage advice from trusted sources.

8. What mediums or channels do you prefer using to learn why an occurrence happened, and our safety messaging? (Select multiple if required)

Mediums, as mentioned above are the preferred option; when industry folk, connected to reality, can't puzzle out what happened about three years ahead of the ATSB soothsayers. Mediums are cheaper, more convenient and will answer a question almost immediately. We could save some money if ATSB just stopped publishing – well anything other than your weekly Horoscope and Lotto numbers.  That at least could be taken seriously – Godley's statistical pick for next week – that'll work.

9. What would you like us to do more of or start doing?

Leave the building in good order, depart quietly and DO NOT startle the horses; there's good chaps.


10. If you have any constructive comments about our performance, how we communicate or how we can improve, please let us know below:

Aye well, I've tried to help 'em; waste of wind and time I know – but you see I remember a time when ATSB (BASI) was a good as any and a lot better than most. It shames this nation to witness a public relations based, ministerial cats paw and CASA catamite continue to embarrass a once proud reputation for excellence in accident investigation. Lockhart River broke their hearts; the MoU destroyed them – the rest is history.

Selah.

[Peetwo]

AOPA Oz response to Hooded Canary's bollocks survey - 

Via BM CEO AOPA Oz:

---

ATSB SURVEY: HOW GOOD ARE THEY?
June 3, 2020 By Benjamin Morgan

Here is your chance to provide some feed back to the ATSB.



The Australian Transport Safety Bureau is seeking industry participation in an online survey on the effectiveness of their stakeholder engagement and communications channels.

Survey Link:  https://www.atsb.gov.au/media/news-items...sb-survey/

The survey will close as of 30 June.

I would encourage AOPA Australia members and industry supporters to review my opinion editorial, titled:  ‘What’s Wrong with the ATSB’ before you make your submission.

My response to the ATSB Survey:

Section 10:  Other Comments

ATSB’s data analysis displays a worrying lack of credibility and absence of critical evaluation of the validity of data used in their analyses. ATSB also fails to act on advice from well qualified experts from outside the organisation.

The ATSB was shown by the Senate RRAT Committee to have based its reports on manipulated ‘modeled’ data – rather than seeking actual hard safety data – all done to support a per-determined outcome, that ultimately served to undermine confidence in general aviation nationwide.

The ATSB has destroyed the trust between it and industry and the pilot community, by presenting reports that are focused on political outcomes – not safety.

How can the aviation industry or pilot community trust any report from the ATSB as a result of these and other recent historical inexcusable failures?

For the ATSB to regain trust and respect, if must withdraw report AO-2017-069, and undertake a new investigation and reporting effort using hard ‘actual’ safety data – not made-up, manipulated, modeled data.

BENJAMIN MORGAN, CEO, AOPA Australia.

---

OPINION: WHAT’S WRONG WITH THE ATSB?
May 29, 2020 By Benjamin Morgan

AOPA Australia Chief Executive BENJAMIN MORGAN provides an opinion.


According to its web site, the Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory Agency.  The ATSB is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.

It is improbable that anyone would dispute that ATSB’s function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in:

• independent investigation of transport accidents and other safety occurrences;
  
  
• safety data recording, analysis and research; and
  
  
• fostering safety awareness, knowledge and action.
  

However, many would dispute claims that ATSB achieves excellence in these areas, especially in accident investigation and data analysis.  The aviation community, the Federal Government, the responsible Minister, and the broader community should be alarmed when a government agency, funded by tax-payers, fails to deliver the excellence demanded of it.

Aviation accident investigations

Perhaps the most well-known example of a glaring failure in ATSB’s investigation of an aviation accident is the Norfolk Island accident in November, 2009, involving a Pel-Air Westwind jet VH-NGA on a medical transfer flight from Samoa.

ATSB’s initial report caused a furore in the aviation community and called into question the integrity of both ATSB and CASA.  The criticism was so great that the Senate commissioned an investigation and an independent review by the Transportation Safety Board of Canada.

The Canadian TSB found “lapses in the application of the ATSB methodology with respect to the collection of factual information, and a lack of an iterative approach to analysis”.  It also identified “potential shortcomings in ATSB processes, whereby errors and flawed analysis stemming from the poor application of existing processes were not mitigated”; and it “did not address key issues in the way that the Australian aviation industry and members of the public expected.”

In December, 2014, ATSB was directed to withdraw its report and re-open the investigation.

At least two recent accident reports demonstrate that those lapses, lacks and flaws still exist and that the ATSB does not have nor deserve the respect and support of the aviation industry.

Example 1

The investigation into a fatal crash of a private flight at Mt. Gambier in 2017 (AO-2017-069) has been roundly criticised for its flawed statistics that were shown by independent statistical experts to be invalid.  The investigation paid scant attention to the primary cause of the accident, which was, quite obviously, a decision by the pilot to fly into adverse weather.  No attention was paid to practical matters that would help other pilots avoid similar mistakes in the future e.g. the numerous sources of weather data available to pilots before and during flights.  Instead, the majority of the report was devoted to unproven speculation about real and perceived pressures to continue with the flight.

There have since been at least two more fatal accidents involving private flights where adverse weather prevailed at the time, one near Coffs Harbour and one near the NSW/QLD border.

ATSB was deficient in “the collection of factual information”.  The report contained no evidence of an attempt to determine the mental state of the pilot or his approach to risk management nor any evidence that ATSB consulted other pilots who conducted similar flights.

The report also contained “errors and flawed analysis” as demonstrated by the independent expert analysis.

The final report and the CASA Legislative Instrument (CASA 09/2019) were the subjects of a Senate inquiry in 2019 where the performance of both organisations was heavily criticised.  The Senate committee recommended that CASA amend the Legislative Instrument it introduced (CASA ignored the recommendation).  The Instrument was also the subject of a Senate disallowance motion which, despite the findings of the inquiry, was lost.

Example 2

Almost three years after the event, ATSB has recently released its report into a fatal accident at Renmark in 2017.

Despite an almost complete absence of flight data, ATSB has taken three years to produce a 75 page report, almost all of which is either speculation or of dubious relevance.  For example, although the aircraft had a current maintenance release and no technical were identified during the investigation, the report includes a list of recent maintenance activities, none of which contributed to the accident.

Safety data recording and analysis

ATSB has recently released a research report AR-2020-014 Aviation Research Statistics.  The report is an example of analysis that falls well short of excellence.  For example, the report contains a statement that “Community services flights, followed closely by test and ferry flights, had the highest fatal accident rates”. The statement is completely invalid and calls into question the ability of ATSB to provide effective, reliable and independent analysis of accidents and incidents.

There are two very serious failures in the analysis on which the statement is based.

First, it is contradictory.  ATSB acknowledges that “as there was only one fatal accident involving an aircraft conducting community service flights between 2014 and 2018 there is a high level of statistical uncertainty associated with this rate”.  Having acknowledged the absence of any statistical significance, ATSB nonetheless claims that community service flights “had the highest fatal accident rate”.  Making such a statement on the basis of a single event is a blatant misrepresentation of the facts.

The second and equally serious deficiency is the failure to consider the validity of the data on which the statement is based.  According to the report, ATSB obtained “activity departures and hours flown data from the Bureau of Infrastructure, Transport and Regional Economics (BITRE)”. ATSB should be aware, and failed to acknowledge, that the BITRE survey seeks data on aircraft use from owners and operators whose source of information is the maintenance release of each aircraft.  There is no requirement, and no facility on the maintenance release, to record the activity for which an aircraft is used.  Thus, the only operators who can provide data on community service flying are owners who are the sole users of their aircraft and can, therefore, match aircraft use with pilots’ log books.  Consequently, the data for community service flights will, inevitably, be seriously underestimated.

What does the aviation industry need?

• The Minister should require that ATSB immediately withdraws its report AR-2020-014 Aviation Research Statistics, acknowledges the deficiencies in the BITRE data on community service flights, and retracts the statement that “Community services flights, followed closely by test and ferry flights, had the highest fatal accident rates”.
  
  
• The Minister should commission an independent audit of the performance of ATSB in relation to its independence in investigating transport accidents and other safety occurrences; the quality of its safety data recording, analysis and research; and the relationship between ATSB and the aviation industry. The audit should be conducted by a panel comprising a majority of aviation industry representatives, selected by the industry.
  
  
• The Minister should set quantitative and relevant performance indicators for the ATSB commissioners and the overall organisation with appropriate consequences for failure to meet the required performance.
  
  
• There should be a process for independent review of ATSB reports and investigations, preferably judicial review/Federal Court appeal process.
  
  
• The Prime Minister should appoint an Assistant Minister for Civil Aviation and introduce a new Civil Aviation Act that actively encourages a vibrant aviation industry and requires both CASA and ATSB deliver efficient, relevant and cost effective services to the aviation industry.
  

---

MTF...P2 

[Peetwo]

AOPA Oz response to Hooded Canary's bollocks survey - 

Via BM CEO AOPA Oz:

---

ATSB SURVEY: HOW GOOD ARE THEY?
June 3, 2020 By Benjamin Morgan

Here is your chance to provide some feed back to the ATSB.



The Australian Transport Safety Bureau is seeking industry participation in an online survey on the effectiveness of their stakeholder engagement and communications channels.

Survey Link:  https://www.atsb.gov.au/media/news-items...sb-survey/

The survey will close as of 30 June.

I would encourage AOPA Australia members and industry supporters to review my opinion editorial, titled:  ‘What’s Wrong with the ATSB’ before you make your submission.

My response to the ATSB Survey:

Section 10:  Other Comments

ATSB’s data analysis displays a worrying lack of credibility and absence of critical evaluation of the validity of data used in their analyses. ATSB also fails to act on advice from well qualified experts from outside the organisation.

The ATSB was shown by the Senate RRAT Committee to have based its reports on manipulated ‘modeled’ data – rather than seeking actual hard safety data – all done to support a per-determined outcome, that ultimately served to undermine confidence in general aviation nationwide.

The ATSB has destroyed the trust between it and industry and the pilot community, by presenting reports that are focused on political outcomes – not safety.

How can the aviation industry or pilot community trust any report from the ATSB as a result of these and other recent historical inexcusable failures?

For the ATSB to regain trust and respect, if must withdraw report AO-2017-069, and undertake a new investigation and reporting effort using hard ‘actual’ safety data – not made-up, manipulated, modeled data.

BENJAMIN MORGAN, CEO, AOPA Australia.

---

OPINION: WHAT’S WRONG WITH THE ATSB?
May 29, 2020 By Benjamin Morgan

AOPA Australia Chief Executive BENJAMIN MORGAN provides an opinion.

Boyd Munro's blast from the past - 

From over on the 20/20 hindsight thread "K" posted this: 18 Across: 'A moral obligation; perhaps'.

Quote: ..If we are to demand changes, the first item of business (IMO) is to bring the 'agencies' to heel, make 'em responsible and accountable – under law to the parliament. Until there is an enforceable 'Act' which obliges them to make the changes and address the edicts of a Senate Committee; or, explain why not – then we are simply pissing into the wind - again.

The RRAT committee had a taste of what they face with the Angel Flight shambles. The committee need look no further back than the Pel-Air scandal to see the contempt in which their 'recommendations' were treated and the insult to the good Rev. Forsyth report. Should the committee want to ask questions; perhaps they could start there. Review their own, the Canadian and Forsyth's recommendations and simply ask 'please explain'. Why have none of these been paid anything more than lip service?  The answer is simple enough - “Not obliged to M'lud”...

The reference to the Rev Forsyth report got me reflecting on the historical lead up to the good Reverend's review and dredging through the UP Truss ASRR thread posts from before the Forsyth report was  handed down, I was drawn to this 2013 NYE post of mine...

Food for thought and a blast from the past for 2014??

In particular I would like to reflect on the quoted 2004 article from Boyd Munro and how much things have changed for the ATSB - err NOT!

KEEP A LITTLE SALT HANDY THIS WEEK, PLEASE …
IN CASE ANOTHER ATSB REPORT COMES OUT


I urge members of the Press Corps to keep a grain or two of salt handy this week. It may be needed when ATSB publishes its report into the Aviation Incident which occurred near Launceston on Christmas Eve.

The Report will probably be released this week, and it may contain the kind of inaccuracy for which the ATSB is rapidly developing a reputation. Before you go to camera, microphone or print on it, please contact us by phone or e-mail so we can – if necessary - tell you what ATSB may have chosen not to reveal.

The Aviation Incident is being beaten up for industrial reasons. Changes were made to Australia’s management of airspace. These changes take us part of the way out of the “quill pen and green eye-shade” era in which our airspace management has been for the past 50 years. Our airspace is now managed like that of the USA, which has an outstanding safety record – and there is far more flying in the USA than in any other country.

Those changes, sadly, are apparently seen by the leaders of the Air Traffic Controllers’ Union as a threat to their members’ jobs rather than the opportunity for professional development that they are,

The relationship between ATSB and the Air Traffic Controllers is a close one – so close that ATSB appointed a former Air Traffic Controller to investigate this incident.

ATSB has been widely criticised for its conduct of investigations. For example –

Mr. Wayne Chivell - Coroner, South Australia, July 2003

"Mr. Fearon was made available by the ATSB to answer as many questions as he could arising from Mr. Cavenagh's evidence.

"The difficulty I have with Mr. Fearon's evidence on this topic is that he is happy to seize upon data, such as that produced by Mr. Braly, as supporting his theory, but when contradictory data was put to him he reverted to rather facile positions.

"......Mr Fearon's evidence became unhelpfully speculative.

"I find the ATSB's theory, namely................., as to be so unlikely as to be almost fanciful.

"In my opinion, the evidence is overwhelmingly against the ATSB theory...........

"As each of these technical issues were put to (The ATSB's) Mr. Cavenagh and Mr. Fearon their explanations and arguments became more abstruse and less credible. I gained the very distinct impression that this constituted an ex post facto justification for a conclusion that had already been reached rather than a genuinely dispassionate scientific analysis of the factors involved.

Ms Lyn McDade - Deputy Northern Territory Coroner, March 2003.

"ATSB apparently acting on the advice of others determined that they would not attend the accident site because it appeared to be an accident involving pilot error only. The basis for that determination could not be explored... ...because Mr. Heitman the ATSB representative who made that determination was not able to give evidence because he could not be located. This has deprived the family of the opportunity to test Mr. Heitman and ascertain why he formed the view about the accident he clearly did, without attending the scene or conducting any other enquiries other than telephone contacts with, it appears, Senior Sergeant B and nobody else."

Mr. Alistair Hope - Coroner, Western Australia, September 2002

"I should stress at the outset that any comments in relation to the performance of the ATSB are made in the context where eight people have unnecessarily lost their lives, such a tragic event in my view requires careful analysis of available evidence and where answers are not forthcoming because of a lack of evidence, an examination should take place as to the way in which evidence has been obtained and possible deficiencies in obtaining evidence identified, which should be corrected in future cases if such tragedies are not to be repeated on a continuing basis."

Mr. Kurt Mackiewicz - Father of deceased pilot, on the ABC in July 2003

"The protracted investigation was attributable to the ATSB's questionable culture and also their arrogant and obstructionist conduct at the inquiry."

Mr. Peter Scollard – Pilot involved at Launceston, in the Hobart Mercury on December 29th. 2003

"I was fully aware of the Virgin Blue plane's presence at all times, I was monitoring it on two radio frequencies and I was maintaining separation. It is quite simple for me to diverge one or two degrees. At no stage was there ever going to be a collision or even a near-collision."

Peter has good reason for concern. ATSB has not given him a copy of the transcript of the radio transmissions at the time of the incident, even though he took part in the transmissions. If all ATSB was doing was carrying out a “no blame” investigation, why on earth would they not give him a copy so that he could, for example, point out any transcription errors? To make matters worse it seems that a copy of that transcript, or a tape of the transmissions, has been made available to others!

If you were investigating with the intention of finding out what had happened, once you has made a transcript of a recording wouldn’t you send it to ALL those whose voices were on the tape asking them to verify the transcription? But if you were seeking “an ex post facto justification for a conclusion that had already been reached” (to quote Coroner Chivell) then you might well be selective about who got the transcript and who did not.

So keep that salt handy and be sure to give us a call on 08 8276 4600 if you feel an urge to report on whatever character assassination it is that ATSB has in store for Peter.

Boyd Munro
AIR SAFETY AUSTRALIA

Hmm..wonder what Boyd would make of the Hooded Canary's bollocks survey?? 

MTF...P2 

[Peetwo]

AO-2017-118 : Cover-up or cock-up?

Spot the disconnections in this load of twaddle?

This AM the Hooded Canary released this media release for the O&O'd investigation AO-2017-118 (Collision with water involving a de Havilland Canada DHC-2 Beaver aircraft, VH‑NOO, at Jerusalem Bay, Hawkesbury River, NSW on 31 December 2017) - 

Prevent and detect carbon monoxide in aircraft

The Australian Transport Safety Bureau is advising owners, operators, pilots and maintainers of piston-engine aircraft to take measures to detect the presence of, and prevent the entry of, carbon monoxide in aircraft cabins.

The national transport safety investigator is today issuing two Safety Advisory Notices and releasing an update to its on-going investigation into the collision with water of a DHC-2 Beaver floatplane at Jerusalem Bay, on the Hawkesbury River north of Sydney, on 31 December 2017, in which the pilot and five passengers lost their lives.

“During the draft review process for the investigation’s final report, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide toxicology testing be undertaken on blood samples of the aircraft occupants,” said ATSB Chief Commissioner Greg Hood.
The results of that testing, provided to the ATSB in March 2020, indicated that the pilot and two of the passengers, whose post-mortem examinations established received fatal injuries sustained as a result of the impact sequence, had elevated levels of carbon monoxide.

Accident aircraft’s engine exhaust crack

Note pre-existing crack spread and widened during the impact.  Source: ATSB

Subsequent to receiving those results the ATSB consulted widely with medical experts to fully understand those results.

“From that consultation with medical experts, and research into the effects of carbon monoxide on aircraft operations, the ATSB considers the levels of carbon monoxide were likely to have adversely affected the pilot’s ability to control the aircraft,” Mr Hood said.

The ATSB then re-examined the accident aircraft and undertook testing on an exemplar Beaver aircraft to replicate the potential source of carbon monoxide and ingress into the aircraft cabin.

“Having discounted other potential sources of carbon monoxide exposure, the ATSB considers it likely that the pilot and passengers were exposed to carbon monoxide inside the aircraft cabin,” Mr Hood said.
“The ATSB found pre‑existing cracking of the engine exhaust collector-ring, which could lead to exhaust leakage into the engine bay. Further, the ATSB found a breach in the firewall from missing bolts used to secure magneto access panels in the firewall under the instrument panel in the cabin. Any breach in the firewall can allow the ingress of gases from the engine bay into the cabin.” 
The aircraft had departed from Cottage Point and taxied for about seven minutes before taking off on its planned return trip to Rose Bay. Shortly after take-off, the aircraft deviated from the operator’s standard flight path, stopped climbing, and entered the confines of Jerusalem Bay below the height of surrounding terrain. The aircraft then continued along the bay, made a very steep right turn, and collided with the water.

The confirmation that there were elevated levels of carbon monoxide in the pilot’s blood, and the potential for engine exhaust gases to exit the exhaust system in the engine bay and enter the aircraft’s cabin has prompted the ATSB to issue the two Safety Advisory Notices to industry.

“This investigation is on-going, and our final report, which will contain specific findings, is anticipated to be released in coming months, so we are limited in discussing specific details. However, if at any time during an investigation, should the ATSB identify issues that are critical to safety, we will immediately notify relevant stakeholders so proactive safety action can be taken to help prevent similar occurrences,” said Mr Hood.

Accident aircraft’s engine firewall showing the location of missing bolts
[b][/b]
Source: ATSB
“That is why today the ATSB is publishing two Safety Advisory Notices focused on the prevention and detection of carbon monoxide in piston-engine aircraft.”

Although the accident aircraft involved a DHC-2 Beaver, these issues are relevant to piston-engine aircraft in general, Mr Hood noted.

“The ATSB is reminding aircraft maintainers that the primary mechanism for the prevention of carbon monoxide exposure to aircraft occupants is to carry out regular inspections of aircraft exhaust systems to identify and repair holes and cracks, and to detect breaches in the firewall,” he said.

The ATSB is also highlighting the limitations of disposable carbon monoxide chemical spot detectors, as used commonly in general aviation, and was fitted to the accident aircraft.

Spot detectors have a limited shelf-life, can be affected by factors such as direct sunlight and cleaning chemicals, and are passive, relying on pilots to regularly monitor them.

“In contrast, electronic active carbon monoxide detectors are designed to attract the pilot’s attention through auditory and/or visual alerts when carbon monoxide levels are elevated,” Mr Hood said.

“These detectors are now inexpensive and widely available. Had there been an alert of the presence of carbon monoxide, the pilot would have been able to take measures to reduce the risk to those on board.”

Mr Hood noted that the ATSB has kept the Civil Aviation Safety Authority (CASA) informed as to the investigation’s progress. To date, CASA has contacted all operators and owners of the 20 DHC-2 Beaver aircraft registered in Australia to emphasise the importance of inspections of the exhaust system, to confirm that the scheduled inspections were being conducted, and to seek information pertaining to the number of exhaust ring segments requiring repair or replacement.

In addition, CASA has published an Airworthiness Bulletin today to highlight the risks and dangers of carbon monoxide poisoning to all piston-engine owners, operators and aircraft engineers, and advising of the fitment of active carbon monoxide detectors.

Read the investigation update AO-2017-118
Read the Safety Advisory Notices AO-2017-118-SAN-001: Inspection of exhaust systems and engine firewalls
Read the Safety Advisory Notices AO-2017-118-SAN-002: Are you protected from carbon monoxide poisoning?

Where's Nat? Not sure why the Hooded Canary fronted this one given he has zip credibility in professional aviation accident investigation circles (especially in NSW) and also because the original front man for this high profile investigation was none other than Nat Nagy? 

Referring to the updated investigation it becomes obvious that HC has merely selectively regurgitated sections of that update:

Update: 3 July 2020


During the draft investigation report review process, the aviation medical specialist engaged by the ATSB recommended that carbon monoxide (CO) toxicology testing be undertaken on blood samples of the aircraft occupants that had been taken and suitably stored by the New South Wales State Coroner. This required testing at a specialised laboratory. With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.

The results of the testing were provided to the ATSB in March 2020, indicating that the pilot and two of the passengers had elevated levels of CO. The ATSB notes that post-mortem examinations established that the pilot and passengers received fatal injuries sustained as a result of the impact sequence.

Since receiving the toxicology results, the ATSB has:

• consulted with New South Wales Health pathology to confirm the integrity of the samples given the preservation method, storage temperature and duration
  
  
• consulted with NSW Health forensic toxicology to confirm the accuracy of testing given the technique used and sample preparation
  
  
• received independent advice from a forensic pharmacologist, and engaged an experienced independent forensic pathologist to advise on the testing and effects of the CO levels found in the occupants
  
  
• undertaken research on CO poisoning and detectors relating to aircraft operations.
  

From this, the ATSB considers the levels of CO detected were likely to have adversely affected the pilot’s ability to control the aircraft during the flight.

Having discounted other potential sources of CO exposure, the ATSB considers it likely that the pilot and passengers were exposed to CO inside the aircraft cabin. To identify the source of CO in the aircraft cabin, the ATSB has:

• conducted a further examination of the aircraft, in particular, the exhaust system and engine firewall, and identified a potential source of CO and path for exhaust gases to enter the aircraft cabin
  
  
• reviewed the aircraft’s maintenance records for scheduled/unscheduled maintenance and inspections carried out on relevant components
  
  
• attended the maintenance facility to examine an exemplar exhaust system in-situ, and to discuss relevant maintenance procedures
  
  
• undertaken ground testing on an exemplar DHC-2 aircraft to replicate the potential source of CO and ingress into the cabin
  
  
• consulted with the Civil Aviation Safety Authority regarding the release of an airworthiness bulletin providing advice on CO issues.
  

From the above activities, the ATSB found pre‑existing cracking of the engine exhaust collector-ring, which could lead to exhaust leakage into the engine bay. Further, the ATSB found a breach in the firewall from missing bolts used to secure magneto access panels in the firewall under the instrument panel in the cabin. 

Any breach in the firewall can allow the ingress of gases from the engine bay into the cabin. 

In order to communicate the significance of the above to the aviation industry, the ATSB has released the following two safety advisory notices, which:

• Remind aircraft maintainers of the importance of conducting thorough inspections of exhaust systems and firewalls, with consideration for potential CO exposure (AO-2017-118-SAN-001).
  
  
• Strongly encourage operators, owners and pilots of piston-engine aircraft to install or carry a carbon monoxide detector with an active warning to alert pilots of elevated levels of CO in the cabin (AO-2017-118-SAN-002).
  

The ATSB is currently documenting the results of the additional work and developing findings for inclusion in the investigation report. The revised draft investigation report will be provided to Directly Involved Parties for a consultation period to provide an opportunity for them to consider and comment on the new information. Following completion of that review, it is anticipated that the final report will be released publicly on the ATSB website during Q3 in 2020.     

So to the disconnection questions - 

Given the known circumstances in the lead up to this tragic accident why was a aviation medical specialist not consulted earlier?

And why isn't it an automatic procedure to request a toxicology and/or pathology from the State Coroner within days of the accident being investigated?

"..With results pending, the ATSB draft report was submitted to Directly Involved Parties (DIPs) in December 2019 for comment.

The results of the testing were provided to the ATSB in March 2020.."

Finally (for now), given the circumstances why would you release the DRAFT report to the DIPs? The insensitivity of that aside, the investigation report has now returned to the 'internal review' stage with the next DRAFT again to be reviewed by the DIPs - UDB!

MTF...P2 

[Kharon]

A Theory Skirting Bullshit.

Disconnects, delays, deception,  and fumbles; about par for the course from ATSB these days. Gods alone know what the relatives and NoK must be going through. But, it is easily discerned; just ask anyone left behind after a fatal – the stories are all hauntingly similar. A tale of denouement delayed and obfuscated story line. Heartbreak city.

That aside; I got curious. Being familiar with the mighty P&W Wasp Junior and having a nodding acquaintance with the Beaver (many decades ago) I did some rough calculations. The engine has nine cylinders; each cylinder is connected to an exhaust 'ring' at the rear of the engine. The engine mount behind that, ahead of the firewall.


It is not a great distance from the pilot's boots, take a look at the pictures. Each cylinder has a 'displacement' of 985 cubic inches. The mathematics are boring; the medical data vague, but, I am not wholly convinced that one cylinder, leaking a small percentage (small crack) of gas, into an even smaller series of 'holes' in the firewall could produce – within the given time frame, enough CO to incapacitate three adults. It may well be possible; but as a racing certainty, I'd put it at long odds. As a contributing factor with complaints of headaches after the flight – OK, we can shorten the odds on that. Anyway, for what it's worth:-

ISU “ The time of exposure, the concentration of CO, the activity level of the person breathing the CO, and the person’s age, sex, and general health all affect the danger level. For instance, a concentration of 400 ppm will cause headaches in 1 to 2 hours. In 3 to 5 hours the same concentration can lead to unconsciousness and death. Physical exertion, with an accompanying increase in respiration rate, shortens the time to critical levels by 2 or 3 fold.

"The longer you inhale the gas, the worse your symptoms will be. You may lose balance, vision and memory and, eventually, you may lose consciousness. This can happen within 2 hours if there's a lot of carbon monoxide in the air".

"Your symptoms will often indicate whether you have carbon monoxide poisoning, but a blood test will confirm the amount of carboxyhaemoglobin in your blood. A level of 30% indicates severe exposure. "

"Mild carbon monoxide poisoning does not usually need hospital treatment, but it's still important that you seek medical advice."

One would not hesitate to believe a NTSB report on such a theory; but when it comes from the ATSB; the BS meter kicks in. P2 nails down the radical:-

“Where's Nat? Not sure why the Hooded Canary fronted this one given he has zip credibility in professional aviation accident investigation circles (especially in NSW) and also because the original front man for this high profile investigation was none other than Nat Nagy?

"Fiction is obliged to stick to possibilities. Truth isn't."

[Peetwo]

AO-2017-118 : Cover-up or cock-up? - Part II

Interesting OBS "K", after some scrounging around some of the usual cyber-dustbins, I am now leaning towards a cover-up of the cock-up...

Note the following extract from the prelim report -   

The ATSB will continue to consult the engine and airframe type certificate holders, and utilise the expertise of the Seaplane Pilots Association of Australia. Accredited representatives from the Transportation Safety Board (TSB) of Canada and the United States National Transportation Safety Board (NTSB) have been appointed to participate in the investigation. A representative from the United Kingdom (UK) Air Accident Investigation Branch (AAIB) has been appointed as an expert to the investigation team under the same provisions. The AAIB will provide liaison with the passenger’s next-of-kin, citizen’s in the UK.

Given the accident pilot's dual citizenship with Canada, the TSBC reference in particular got me thinking - 

1st reference TSBC AAI report A00C0059 

The following part very much supports the "K" opinion:

Toxicological tests did not reveal the presence of alcohol or any other intoxicating drugs in the blood of the captain or the first officer. However, the levels of carbon monoxide in the blood of both crew members were elevated. The captain's carboxyhaemoglobin level was 17.9 per cent, and the first officer's level was 8.7 per cent. It was learned that the captain smoked more than one package of cigarettes per day and that the first officer was a non-smoker. Cigarette smokers may routinely have saturation levels of 6 to 8 per cent, and the effects of carbon monoxide are cumulative. Tolerance to carbon monoxide is not increased by smoking.

Many different classifications of severity of carbon monoxide poisoning are documented, indicating that the severity of symptoms does not correlate well with carboxyhaemoglobin levels. Generally, saturation levels of less than 5 per cent are not considered to cause any obvious symptoms. At saturation levels less than 25 per cent, physiological functions and the performance of skilled physical tasks are rarely affected. However, complex psychological functions involving judgement, situational decisions, and responses would be affected by levels between 5 and 20 per cent.Footnote3 Some classifications indicate decreased visual acuity at saturation levels of 10 to 20 per cent.Footnote4 Once the victim of carbon monoxide poisoning is removed from the carbon monoxide source, the levels decline. Information indicates that the half-life of carboxyhaemoglobin is about five hours. Altitude affects the saturation level because the partial pressure of oxygen decreases with altitude. Information concerning the altitude of the flights was not available.

The next reference provides a 'passing strange' coincidence in timing with the ATSB's belated, nearly 2 year request for toxicology review of the accident victims blood samples held by the NSW Coroner's office - https://www.tc.gc.ca/en/services/aviatio...019-07.pdf - note the release date was 12 December 2019...

CO has no color or odor. The onset of CO poisoning
can be insidious: victims are often unaware that their
environment is contaminated by this poisonous gas
and that their mental and physical functions are
being degraded. For these reasons, a CO warning
device is a very sensible investment for owners and
operators of GA aircraft. A suitable CO detector will
provide reliable, early warning of elevated levels of
this poisonous gas, allowing the pilot to take
appropriate actions. A CO detector can also
enhance the effectiveness of aircraft maintenance
actions. An inspection of the aircraft cabin with a
detector can confirm that maintenance or repair of
the exhaust or heating systems has corrected and/or
not introduced damage that could be associated with
the CO leaks. The type of functional check enabled
by a CO detector is not otherwise possible.

TC has concluded that preventive actions in addition
to those required by AD CF-90-03R2 may be
beneficial for owners and operators of GA aircraft in
Canada. These additional preventive actions are
described in the following section of this CASA.

So my question is that given the timing of the above Transport Canada CASA and the association of the TSBC with the active investigation, did the powers that be have an 'OH DUCK' moment when they discovered that toxicology reports weren't mandatory done in order to discount possible means of pilot and/or front RHS pax incapacitation?

MTF...P2 

[Kharon]

We need to do better.

There you are; money in the bank, well fed, on holiday, taking off from a beautiful harbour in a classic float plane. You enjoy a flight over some very scenic countryside, thrill at the water landing and toddle off to a great lunch – replete, content and looking forward to the return flight and the Sydney fireworks. No one expected to die, Dec 31, 2017.

Do we know what happened – really. Despite the money, time and effort has anyone provided a reasonable explanation of events? Has the ATSB provided a timely, concise report from which vital improvements to 'safety' will stem? Short, one word answer will suffice.

Do we need to do better than - THIS - ? Damn right we do.

[Peetwo]

Nagging Nagy an Adjunct Professor? - Yeah right...



I know this is a little bit off track but my interest was perked when I read the above blurb for the Nagy ARA webinar?? 

For those interested here is that webinar presentation, via Youtube (be warned you may need a bucket -   ) :

No mention in there of what exactly Nagging Nagy was an 'Adjunct Professor' for? So still curious I decided to visit his Linkedin page: https://www.linkedin.com/in/nat-nagy-a10...bdomain=au 

This was more revealing than I was expecting, mainly because I had an impression that given Nagy's executive manager title that he would have had a professional tinkicker background however the truth was far more troubling than I ever imagined. He'd even put down the bollocks 'Adjunct Professor' as an experience item on his CV - read and absorb...

MTF...P2

[Kharon]

2 Across - Altogether Totally Screwed and Buggered?

I wonder what the American, Canadian and UK next of kin must make of the ATSB. Actually, I wonder what the small world of 'real' accident investigators must make of the dog's breakfast ATSB has become. Me, Oh I just wonder why?

I did try P2 – honest, I did but I couldn't watch the Nagy 'Webinar'. I have sat through many great presentations by 'expert' aviation safety folk – some a little tedious, but always helpful. I would call the Nagy effort more akin to an advertorial – Chanel 7 sort of thing, where you can buy something totally useless – can't watch them either. Nuff said.

The 'Adjunct' professor thing got me interested, I can't see a masters or doctoral degree mentioned – perhaps modesty forbids. But I did a little scratch about on the net to see what it entails.  HERE - FYI. And an extract:-

"Typically, to be considered for a job as adjunct professor, you need a master’s or doctoral degree, though some community colleges or technical schools hiring for these faculty positions may only require a bachelor’s degree along with relevant work experience. Most, however, will require some teaching experience, as well as knowledge of course management software programs such as Blackboard and CourseWeb."

I then wonder what the 'real' tin-kickers – those in ISASI – or even the ASASI make of it all. There are a couple of high profile fatal's involving folk from other lands – with a competent accident investigation record. Aye, Hood's ATSB is indeed a source of wonderment.

Toot – toot.

[Peetwo]

AE-2020-008 :  Technical Assistance to RAAus - Collision with terrain involving BRM Aero Bristell, 24-8555, Kanangra-Boyd National Park, NSW, on 16 December 2019

Summary

On 16 December 2019, a BRM Aero Bristell aircraft, recreational registration 24-8555, collided with terrain in Kanangra-Boyd National Park, near Oberon, New South Wales. The pilot was fatally injured.

In response, Recreational Aviation Australia (RAAus) commenced an investigation into the occurrence and requested technical assistance from the ATSB in the recovery of flight data from two instrumentation units – a Dynon SV-D1000 and Garmin aera 795; both of which were subsequently provided by NSW Police.[/size]

The ATSB successfully downloaded data from both devices, including flight path information and aircraft operational parameters. Figures 1 and 2 summarise this information.

Both instrumentation units were returned to NSW Police on 23 June 2020 and a technical report and all recovered data provided to RAAus on 24 June 2020.

With the completion of this work, the ATSB has concluded its involvement in the investigation of this accident. Any further enquiries in relation to the investigation should be directed to Recreational Aviation Australia.

The information contained in this update is released in accordance with section 25 of the Transport Safety Investigation Act 2003.

Figure 1: Flight paths from Garmin and Dynon units

[b]Source: Google Earth, GPS points by ATSB[/b]
[b]Figure 2: Selected flight parameters[/b]

Source: ATSB

---

---

Why do I get the feeling that the Hooded Canary's aviary was glad to see the back of that particular accident, especially when you consider what the tail end of the GPS vertical profile pictorial appears to show -    

Hmm...a quick referral to the RAAus bollocks 'Accident and defect summaries' page 8:

16/12/2019: Fatal Accident involving RAAus member. RAAus accident consultants are assisting police in determining the causal factors that led to the accident.

Simply put unless the NSW Coroner's office decides to examine further, that'll be the last we hear about that particular fatal LSA (Light Sports Aircraft) accident -   

[Peetwo]

Rossair (AO-2017-057) final report addendum?? 

Trolling through the ATSB investigations for any recent updates etc..etc I noted that for some strange reason there had been an update to the Rossair final report. I am not sure whether this sets a new precedent (ie making ex post facto changes to a published final report) but with help from certain informed sources, I was pointed to an addendum to the final report:

(Ref page 19 of the final report - addendum in bold): "...Additionally, for Cessna 441 aircraft with the serial number 0173 onwards (not applicable to VH-XMJ) the POH, in reference to the ‘engine shutdown to simulate engine failure in takeoff
configuration’ procedure (second procedure), explicitly stated 

“This procedure must not be practiced at an altitude below 5,000 ft AGL”

Some of Rossair’s other Cessna 441 aircraft operated under this later POH, but the operators
manual did not note a difference between the two handbooks.

With respect to the change in the POH procedures applicable to serial number 0173 and onwards,
the aircraft manufacturer advised that:

• there was no material difference between the aircraft from serial numbers 0173 and onwards
and the earlier serial numbers (0172 and prior) that necessitated a different method of
simulating an engine failure in the take-off configuration
• the statements in the earlier POH procedure that referenced the demonstration of VMCA have
the same intent as the warning note in the POH for aircraft with serial numbers 0173 and
onwards, which states this procedure must not be practiced at an altitude below 5,000 feet
above ground level..."

Reading the addendum I wonder why this additional information, obviously from the manufacturer, was a) not captured during the original DIP review process; and why it is considered important enough to include an addendum to an already published final report? I can only surmise that Textron are trying to ensure that there is no legal liability blow back on them when consideration is made on the two differing versions (different a/c models) of the POH and the interpretations for the safe conduct of simulated engine failure in the T/O configuration (ie not to be conducted below 5000'agl) ?

On another point I find it disturbing that to date the (supposedly fully independent) ATSB have not publicly notified an amendment/addendum to the final report? It is also interesting that the addendum itself is not properly annotated with an explanatory footnote for the addendum?

These and other questions -

MTF? - Definitely!...P2

[Kharon]

Here's the thing. (IMO).

After three years; information always available in the Aircraft Flight Manual (AFM) is 'discovered' by ATSB (after confirmation from the certificate holder). Final report – addendum -? Seriously.....

“The ATSB has received some clarifying information from the aircraft manufacturer, regarding the height at which the ‘engine shutdown to simulate engine failure in takeoff configuration’ procedure  is recommended to be performed. The report has been amended with this information and is scheduled to be published on Wednesday 5 August 2020.”

There's a Devil in the detail: “engine shutdown to simulate engine failure in takeoff configuration”.

See - “engine shut down” - not reduced power – or; a 'simulated' engine shut down. The AFM bars a 'shutdown' below 5000'– which opens the loop hole to what is, in effect, the simulation of a 'partial' engine failure (zero thrust). There is no prohibition mentioned regarding this widely accepted practice – provided the engine power is retarded to 'zero thrust' all is well and the hundreds of check flights using this technique have returned to base in one piece. However, as an effective training 'tool' it leaves much to be desired.

It begs the question – which is the 'safer' (I know) practice; an engine 'stopped' at 5000 feet, the engagement of Negative Torques System (NTS) and the drills completed through to restart; or some legally arguable, open to human error procedure which in reality simulates neither a 'real failure' nor the techniques for using the NTS, nor trouble shooting, nor an in flight restart and decision making?

Clearly the 'safety and benefit' question emerges. For an operator to establish an 'in-house' Check and Training System (CTS) the whole box and dice is subject to a three phase scrutiny by the Civil Aviation SAFETY Authority (CASA). In the beginning, the manual supporting the system is submitted for scrutiny by CASA. This is well known to be a long, tedious, difficult process; the requested revisions completed and returned; often, through two or even three constructs. A one size fits all system is acceptable when only one 'type' is encompassed, however, with a mixed fleet there is a substantial amount additional data which must be incorporated. In any event; the practice and procedure for any aircraft must be based on the AFM; particularly on the 'Limitations' section which carries 'real' legal weight. A secondary, but equally important part of the AFM are the 'Warning, 'Caution' and 'Notes' inclusions within the body of the AFM. Open any AFM and those notes jump off the page – usually in 'bold' all capitals – 'Warning' - for example:-

WARNING.

“IF AN ENGINE FAILURE IS ACCOMPANIED BY A LEFT ESSENTIAL BUS FAILURE” etc.

Now; the manufacturer has, clearly and unequivocally stated in the AFM, and now reiterated to ATSB that there was a restriction placed on the height at which a shut down (stopped) Engine Failure after Take Off (EFATO) could be practised; for all variants (mark and model) of the aircraft. Engine shutdown requirements (whistles and bells), trouble shooting, followed by an in flight re-start and recovery is essential training. You can see where fuzzy logic has kicked in; despite clear warning in the AFM and a procedure being specified; BOTH CASA and operator have chosen to ignore this beneficial (from a training standpoint) logic and opted for some half measure which achieves little except 'tick-a-box' with an elevated risk level. The result ending spectacularly with three dead and the associated aftermath of the event. - Good enough?

“With respect to the change in the POH procedures applicable to serial number 0173 and onward, the aircraft manufacturer advised that: • there was no material difference between the aircraft from serial numbers 0173 and onward and the earlier serial numbers (0172 and prior) that necessitated a different method of simulating an engine failure in the take-off configuration • the statements in the earlier POH procedure that referenced the demonstration of VMCA have the same intent as the warning note in the POH for aircraft with serial numbers 0173 and onward, which states this procedure must not be practised at an altitude below 5,000 feet above ground level”.

The Brasilia fatal in the NT was conducted at low level with 'multiple failures' (EFATO and AF fail) at CASA direction; a very close call in Cairns was initiated by the same CASA FOI. The Renmark exercise has parallel 'logic'. It leaves a couple of 'safety logic' questions which demand answers. How was the EFATO check and training system approved by CASA in 'not quite' understanding the spirit, intent and operational logic of the AFM? You see – if you set the pilot a simulated engine problem which requires and 'in-flight' shut down; followed by the system checks; followed by the restart procedure; then set zero thrust and return to land; this constitutes a real check and training scenario. Anything else is essentially an unnecessary exercise which provides very little, except an elevated risk level – for little benefit.

Makes you wonder how many C441 check flights have been conducted in this manner. It may well be OK to do it, an accepted practice; but, what a court and bunch of lawyers will make of it is yet to be seen. It will not be pretty.

Toot – toot.

[Kharon]

Has anyone noticed..

CO poisoning is getting some traction – the local rags have been (Hawksbury Pole Vaulters Journal) and the like has been claiming that CO from the DHC2 exhaust was to blame for the crash, citing ATSB 'results'. (huh?) - CASA have been subtly promoting the notion and, although the big gun newspapers have let it slide – there is a small groundswell of acceptance of the blatant BOLLOCKS being pushed by the ATSB. It is a lovely little get out of jail card to hold; casts lots of smoke to bamboozle and confound. But is it remotely believable?

CO in the pungent exhaust fumes is a serious hazard; no doubt about that, non at all. It is certainly not a thing you want wafting into the cabin. Now, strangely enough; our stalwart, long suffering 'ginger beers' are aware of this. Aircraft manufacturers are also equally aware of the dangers presented. They have even have 'maintenance schedules' and inspections which go to some trouble to determine if there is any 'leakage' from the exhaust system – it is part of ongoing maintenance and airworthiness and carries criminal penalty for non compliance. So the CASA 'deep and meaningful' advice and direction to 'check' becomes utterly superfluous window dressing.

The known facts are getting lost in the spin: let's recap. The BRB 'buzz-word' this week has been – 'elevated'. ATSB come out with 'pilot and passengers had 'elevated' CO levels. But compared to what? The TSBC provided a good report on a CO event; tracked down the leak and stated the CO levels 17% for the Skipper – (from memory). The word 'elevated' is not mentioned, the level was quantified and presented. So what were the 'elevated levels' of the Jerusalem Bay accident?

You see the problem – passengers exposed for what – call it 40 minutes before landing and shuffling off to lunch for a couple of hours; presumably in an atmosphere far removed from CO gas. The pilot took off again and worked for a few more sectors in the aircraft.

The estimated time between passengers re boarding and the accident was what – call it seven minutes. So the comparison between the passengers 'elevated' CO count and the pilot's CO count should reflect a marked difference in toxicology - n'est ces pas? So where are the numbers? Where is the clinical dissection of the percentage difference?

IF and it is possible, the ATSB cannot nicely define the cause of the accident; then that should be stated. There's no shame in it “we explored and investigated all reasonable scenario, but are unable to definitively determine – etc” The CO may have played a part – it may not have. 'Elevated' and minor newspaper articles do not make for a clear cut case of anything - except for Pony-Pooh, evenly spread between the smoke and mirrors.

The poor old Coroner has his work cut out - once again; let's all hope he can do a 'time-line' comparing passenger exposure to the alleged CO intake and the alleged 'pilot intake' and do the maths. That is of course presuming that the 'exhaust leak' was of significant proportion. Was that tested as part of the initial investigation? No. Didn't think so, but why-ever not remains a penny pinching mystery.

Toot – toot.

[Choppagirl]

Here's the thing. (IMO).

After three years; information always available in the Aircraft Flight Manual (AFM) is 'discovered' by ATSB (after confirmation from the certificate holder). Final report – addendum -? Seriously.....

“The ATSB has received some clarifying information from the aircraft manufacturer, regarding the height at which the ‘engine shutdown to simulate engine failure in takeoff configuration’ procedure  is recommended to be performed. The report has been amended with this information and is scheduled to be published on Wednesday 5 August 2020.”

There's a Devil in the detail: “engine shutdown to simulate engine failure in takeoff configuration”.

See - “engine shut down” - not reduced power – or; a 'simulated' engine shut down. The AFM bars a 'shutdown' below 5000'– which opens the loop hole to what is, in effect, the simulation of a 'partial' engine failure (zero thrust). There is no prohibition mentioned regarding this widely accepted practice – provided the engine power is retarded to 'zero thrust' all is well and the hundreds of check flights using this technique have returned to base in one piece. However, as an effective training 'tool' it leaves much to be desired.

It begs the question – which is the 'safer' (I know) practice; an engine 'stopped' at 5000 feet, the engagement of Negative Torques System (NTS) and the drills completed through to restart; or some legally arguable, open to human error procedure which in reality simulates neither a 'real failure' nor the techniques for using the NTS, nor trouble shooting, nor an in flight restart and decision making?

Clearly the 'safety and benefit' question emerges. For an operator to establish an 'in-house' Check and Training System (CTS) the whole box and dice is subject to a three phase scrutiny by the Civil Aviation SAFETY Authority (CASA). In the beginning, the manual supporting the system is submitted for scrutiny by CASA. This is well known to be a long, tedious, difficult process; the requested revisions completed and returned; often, through two or even three constructs. A one size fits all system is acceptable when only one 'type' is encompassed, however, with a mixed fleet there is a substantial amount additional data which must be incorporated. In any event; the practice and procedure for any aircraft must be based on the AFM; particularly on the 'Limitations' section which carries 'real' legal weight. A secondary, but equally important part of the AFM are the 'Warning, 'Caution' and 'Notes' inclusions within the body of the AFM. Open any AFM and those notes jump off the page – usually in 'bold' all capitals – 'Warning' - for example:-

WARNING.

“IF AN ENGINE FAILURE IS ACCOMPANIED BY A LEFT ESSENTIAL BUS FAILURE” etc.

Now; the manufacturer has, clearly and unequivocally stated in the AFM, and now reiterated to ATSB that there was a restriction placed on the height at which a shut down (stopped) Engine Failure after Take Off (EFATO) could be practised; for all variants (mark and model) of the aircraft. Engine shutdown requirements (whistles and bells), trouble shooting, followed by an in flight re-start and recovery is essential training. You can see where fuzzy logic has kicked in; despite clear warning in the AFM and a procedure being specified; BOTH CASA and operator have chosen to ignore this beneficial (from a training standpoint) logic and opted for some half measure which achieves little except 'tick-a-box' with an elevated risk level. The result ending spectacularly with three dead and the associated aftermath of the event. - Good enough?

“With respect to the change in the POH procedures applicable to serial number 0173 and onward, the aircraft manufacturer advised that: • there was no material difference between the aircraft from serial numbers 0173 and onward and the earlier serial numbers (0172 and prior) that necessitated a different method of simulating an engine failure in the take-off configuration • the statements in the earlier POH procedure that referenced the demonstration of VMCA have the same intent as the warning note in the POH for aircraft with serial numbers 0173 and onward, which states this procedure must not be practised at an altitude below 5,000 feet above ground level”.

The Brasilia fatal in the NT was conducted at low level with 'multiple failures' (EFATO and AF fail) at CASA direction; a very close call in Cairns was initiated by the same CASA FOI. The Renmark exercise has parallel 'logic'. It leaves a couple of 'safety logic' questions which demand answers. How was the EFATO check and training system approved by CASA in 'not quite' understanding the spirit, intent and operational logic of the AFM? You see – if you set the pilot a simulated engine problem which requires and 'in-flight' shut down; followed by the system checks; followed by the restart procedure; then set zero thrust and return to land; this constitutes a real check and training scenario. Anything else is essentially an unnecessary exercise which provides very little, except an elevated risk level – for little benefit.

Makes you wonder how many C441 check flights have been conducted in this manner. It may well be OK to do it, an accepted practice; but, what a court and bunch of lawyers will make of it is yet to be seen. It will not be pretty.

Toot – toot.

Out of interest, when EFATO training is conducted in a simulator, is a full engine shut-down performed? If so, is it done at low altitude?

And another question, does CASA have the authority to sidetrack the AFM by introducing simulated engine failures at much lower levels than stated and justifying it by not actually shutting the engine down? I would be very interested to know where such authority comes from which allows them to make up rules which are contrary to the intentions of the aircraft manufacturer.

[Kharon]

A can of worms;

CG - “ Out of interest, when EFATO training is conducted in a simulator, is a full engine shut-down performed? If so, is it done at low altitude?”

and, a piece of string. For CG - Much depends on the 'Sim' being used. I have been in one (USA) for an aircraft with 'auto-feather' and a co-pilot. Dead cut at VR – nothing to do except control the aircraft and confirm 'Auto feather' – that's it. However what one is supposed to do should the AF system fail is a mystery, and a tale for another day. There is not to my knowledge a Conquest sim in Australia; but the Metro sim supports the Negative Torque System (NTS). Personalty – I like the NTS – it offers an almost instant relight option – but an increased 'decision' time frame – time needed to decide whether the donkey is dead or just fooling. Either way - at low level, low speed, with gear and flap out, the essential thing is eliminate the propeller drag resulting from a failed engine – both systems are very effective at doing exactly that. Where the Sim wins, hands down, is that engine failure (dead cut) can be 'properly' simulated – and the 'drill's' and decision process can be safely executed, practised until almost second nature. Using an aircraft involves a compromise. No sane person is going to dead cut an engine in a FAR 23 aircraft at V1, VR or even higher. So 'Zero thrust' enters the picture. Nothing wrong operationally with it; been around a long, long time. Properly done it achieves the purpose of the lesson – and provided the check pilot has instant access to the power lever (to be sure to be sure) then there is an acceptable, reasonable level of equivalent safety. 'Cost' is the big threat – closely followed by wear and tear on the aircraft. Again, properly managed these elements can be reduced – it all depends on individuals and company 'ethos'. I find it difficult to criticise the use of 'zero thrust' – it is effective and; as said, properly done is a safe training tool. But No, in real life the 'shut down' of a healthy engine just after take off is simply not done. Shut down and relight is always practised at a sensible height and is a mandatory part of training for a type rating.

CG - “And another question, does CASA have the authority to sidetrack the AFM by introducing simulated engine failures at much lower levels than stated and justifying it by not actually shutting the engine down? I would be very interested to know where such authority comes from which allows them to make up rules which are contrary to the intentions of the aircraft manufacturer.”

More worms – the manufacturer cites 'shut down' along with the height requirement. To me it relates back to initial training on type – the notion of a deliberate 'shut down' followed by 'checks' followed by a relight. Without a C441 manual in front of me, I can't say what other practices the AFM provides for. There will be a 'zero thrust' setting; the C&T system would incorporate that and practice EFATO should incorporate that, alongside clearly defined parameters. These should be defined within the AFM and built into the C&T system. CASA have a requirement for demonstration of EFATO in their testing requirements and fairly loose interpretation of 'how' this element can be tested. In fairness, this is an operator responsibility. Say CASA demanded a 'shut-down' on take off – the operator has two options – bugger off, not happening; or, use a manufacturer 'zero-thrust' setting. If the operator can demonstrate that what CASA ask for is contrary to the AFM – then an alternative method can be negotiated; if not, then CASA rules apply. Much depends on the actual words writ in both AFM and the operators system and the negotiated settlement with the CASA. Compromise for certain; but not even CASA would dare to ride rough shod over the AFM – well, not in writing at least. The Ross Air crash falls into a compromise; zero thrust not shut down. The height and speed at which the simulated failure occurred demonstrated nothing of value; too high and fast to represent a 'true' EFATO; too low and slow for a 'shut down' relight scenario. Box ticking at it's very best. The real question is should that event have ever taken place – was it necessary?

Coffee – must have; hope that blurb helps. But bare faced breach of the AFM will be a tough row to hoe; proving it - mission impossible.

Toot – toot.

[Kharon]

A game of shadows.

It was a simple enough question – one posed to the BRB as a follow up to the twiddle I stuck on the board – HERE -. The response not only unanimous but completely unambiguous – stunned disbelief.

The Hawkesbury (spell checked for ST) river crash of a Beaver was one of those 'mystery' ones; competent pilot, safe aircraft, good weather etc. Not clear cut, similar to the Essendon King Air event – i.e. why and what the Hell happened.

Dec 31, 2017 was the date of the event – today is August 12, 2020. Only recently have folks like the ABC picked up the story line of CO gas in the exhaust fumes as being the villain in the piece.

Would you expect that as soon as possible there would be an autopsy conducted?

Could you reasonably expect ATSB to factor in the results of that examination to the reporting process, in the first instance – as soon as possible?

With an event like the Jerusalem Bay fatal; the early discovery of any toxic, mind bending or prescribed chemicals would be an essential consideration – ruled in or out as the case may be.

After two years and eight months ATSB start whispering that CO in the exhaust gas killed the aircraft and its passengers? Seriously -

It may well be that CO did for the pilot and passengers; but, if so, then why was this not made public at the time of autopsy – or at least as soon as legally possible; with a final report stating this as 'proven fact', with supporting evidence? Gold plated, cash and no bull-shit evidence would have put the matter to bed with hardly a ripple. “Pilot incapacitated; CO level of 25%; end of story. But no, we get fed a line of 'elevated' CO levels; a small lately discovered 'crack' in one exhaust pipe and some tiny (PK screw size) holes in the firewall. How many thousands of hours have been flown in the Beaver by pilots on long days of top dressing and all the other utility jobs the Beaver has been use for in its long history – you think none of those aircraft had leaky exhaust gaskets, cracks in the manifold or even the odd hole or two in the firewall?

Is feeding half baked stories to the media the right way to wrap up a two year eight month investigation?

Toot – toot.

[Peetwo]

A can of worms;

CG - “ Out of interest, when EFATO training is conducted in a simulator, is a full engine shut-down performed? If so, is it done at low altitude?”

and, a piece of string. For CG - Much depends on the 'Sim' being used. I have been in one (USA) for an aircraft with 'auto-feather' and a co-pilot. Dead cut at VR – nothing to do except control the aircraft and confirm 'Auto feather' – that's it. However what one is supposed to do should the AF system fail is a mystery, and a tale for another day. There is not to my knowledge a Conquest sim in Australia; but the Metro sim supports the Negative Torque System (NTS). Personalty – I like the NTS – it offers an almost instant relight option – but an increased 'decision' time frame – time needed to decide whether the donkey is dead or just fooling. Either way - at low level, low speed, with gear and flap out, the essential thing is eliminate the propeller drag resulting from a failed engine – both systems are very effective at doing exactly that. Where the Sim wins, hands down, is that engine failure (dead cut) can be 'properly' simulated – and the 'drill's' and decision process can be safely executed, practised until almost second nature. Using an aircraft involves a compromise. No sane person is going to dead cut an engine in a FAR 23 aircraft at V1, VR or even higher. So 'Zero thrust' enters the picture. Nothing wrong operationally with it; been around a long, long time. Properly done it achieves the purpose of the lesson – and provided the check pilot has instant access to the power lever (to be sure to be sure) then there is an acceptable, reasonable level of equivalent safety. 'Cost' is the big threat – closely followed by wear and tear on the aircraft. Again, properly managed these elements can be reduced – it all depends on individuals and company 'ethos'. I find it difficult to criticise the use of 'zero thrust' – it is effective and; as said, properly done is a safe training tool. But No, in real life the 'shut down' of a healthy engine just after take off is simply not done. Shut down and relight is always practised at a sensible height and is a mandatory part of training for a type rating.

CG - “And another question, does CASA have the authority to sidetrack the AFM by introducing simulated engine failures at much lower levels than stated and justifying it by not actually shutting the engine down? I would be very interested to know where such authority comes from which allows them to make up rules which are contrary to the intentions of the aircraft manufacturer.”

More worms – the manufacturer cites 'shut down' along with the height requirement. To me it relates back to initial training on type – the notion of a deliberate 'shut down' followed by 'checks' followed by a relight. Without a C441 manual in front of me, I can't say what other practices the AFM provides for. There will be a 'zero thrust' setting; the C&T system would incorporate that and practice EFATO should incorporate that, alongside clearly defined parameters. These should be defined within the AFM and built into the C&T system. CASA have a requirement for demonstration of EFATO in their testing requirements and fairly loose interpretation of 'how' this element can be tested. In fairness, this is an operator responsibility. Say CASA demanded a 'shut-down' on take off – the operator has two options – bugger off, not happening; or, use a manufacturer 'zero-thrust' setting. If the operator can demonstrate that what CASA ask for is contrary to the AFM – then an alternative method can be negotiated; if not, then CASA rules apply. Much depends on the actual words writ in both AFM and the operators system and the negotiated settlement with the CASA. Compromise for certain; but not even CASA would dare to ride rough shod over the AFM – well, not in writing at least. The Ross Air crash falls into a compromise; zero thrust not shut down. The height and speed at which the simulated failure occurred demonstrated nothing of value; too high and fast to represent a 'true' EFATO; too low and slow for a 'shut down' relight scenario. Box ticking at it's very best. The real question is should that event have ever taken place – was it necessary?

Coffee – must have; hope that blurb helps. But bare faced breach of the AFM will be a tough row to hoe; proving it - mission impossible.

Toot – toot.

P2 addendum:  Can of worms alright?? 

Especially when you add in (my bold)...

ref pg 19: "..One engine inoperative procedures should be practiced in anticipation of an emergency. This practice should be conducted at a safe altitude (5000 ft AGL), with full power on both engines, and should be started at a safe speed of at least 98 KIAS. As recovery ability is gained with practice, the starting speed may be lowered in small increments until the feel of the airplane in emergency conditions is well known. It should be noted that as the speed is reduced, directional control becomes more difficult. Emphasis should be placed on stopping the initial large yaw angles by the IMMEDIATE application of rudder supplements by banking slightly away from the yaw. Practice should be continued until: (1) an instinctive corrective reaction is developed and the corrective procedure is automatic, and (2) airspeed, altitude and heading can be maintained easily while the airplane is being prepared for a climb..."

Note that there is no mention about shutting down an engine; nor the procedure to follow for shutting down an engine?? 

 

ref pg 19-20: "..Simulated asymmetric flight is not to be carried out unless specifically authorised, and then only when accompanied by an authorised person. Asymmetric flight shall not be carried out when passengers are being carried and shall only be conducted on a designated training flight.

Any engine failure simulation shall be conducted by closing the power lever to a position equivalent to zero thrust (Turbine) in accordance with Part C, or moving the mixture lever to the idle cut off position (Piston).

For the purpose of training, simulated engine failures and the feathering of aircraft propellers shall only be conducted in VMC conditions. In addition, the aircraft shall be operating above 3000 ft AGL, unless the simulation or feather practice is specifically required during the approach and landing phase.

Following any practice engine shut-down in flight, the engine controls must be set for an immediate restart.

At no time are stalling or Vmca demonstrations to be made with the aircraft propeller feathered..."

Plus:

Figure 12: Rossair training and checking manual