[Peetwo]

A closed safety loop - found one!  

Caught this via the NT News:

Chopper crash could have been multiple fatality if not for fuel tank standards changes

JASON WALLS, NT News
January 20, 2018 1:00am

THE helicopter crash in Central Australia which left two men with spinal injuries this week could have been a multiple fatality if not for changes to fuel tank standards sparked by a series of earlier deadly crashes.

The design of the Robinson R44 model helicopter involved in the crash was changed after three similar crashes in NSW resulted the deaths of eight people between 2011 and 2013.

In the most recent incident, which bears eerie similarities to Wednesday night’s crash, the pilot and three passengers were killed when the chopper they were in rolled onto its side after striking trees.

The deaths were attributed to a fire which started when the helicopter’s aluminium fuel tank leaked “following an otherwise survivable impact”.

That incident led to action from the Civil Aviation Safety Authority, which now requires a bladder-type fuel tank to be fitted in all R44s in Australia as well as other fuel system improvements.

There are 52 R44s registered as operating in the Northern Territory and Wednesday’s crash is the third in the NT since 2016 involving an R44 or its two-seater counterpart, the R22.

None of those crashes have been fatal and no injuries were reported in the two previous incidents.

An Australian Transport Safety Bureau spokesman said it was too early in the investigation to say conclusively whether the fuel tank change prevented the deaths of all those on board on Wednesday.

“However, it is expected that the mandated change to bladder-style fuel tanks for all R44 helicopters in Australia would have reduced the risk of a post-impact fire in this occurrence,” he said.

The 46-year-old woman injured in Wednesday’s crash was flown to the Royal Adelaide Hospital on Friday in a serious but stable condition.

The 32-year-old pilot and his 32-year-old passenger already in hospital in Adelaide were in a stable and serious condition respectively. The other passenger, a 35-year-old man, suffered minor injuries.

 I am sorry to burst the 'NT News' scoop bubble but if they'd bothered to dig a little deeper they may have discovered that the identified safety issue predated those (2011-2013) NSW reoccurrences for the better part of 15 years (now 2 decades). And if it wasn't for the lobbying of certain fatal victims NOK (like the Cousins in WA) and the efforts of a certain Senate Committee, we may have been witness to another fiery fatal Robbo accident...

Reference: Sunday Ramble - Beyond the pale 

..Some on here will remember that at Budget Estimates in May 2013 (i.e. 2 months after the tragic Bulli tops accident), the matter of the R44 post impact fire accidents were the subject of Senate questioning. Here is a copy of a post of mine off the UP from that time:

Yep the list is growing and the stench is rising!

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You can add the Cousin's to that list...remember this from sub16:

“We have been to Martin Dolan Chief Commissioner ATSB, Albanese, John McCormick, Local Member John Castrilli - who did write a letter to CASA on our behalf but that was it! John McCormick insulted us in his response stating that "CASA is unaware of any other accidents involving this company’s aircraft". Oh My God how insulting to our intelligence. So in their eyes Kenny's Mob have never been involved in other incident!

How many fatalities does a Company need to have to be anything recorded as an ACCIDENT! At the inquest the CEO of Heliworks was questioned about his Statutory Declaration and had he completed - he disclosed he did not complete it and the Company had told him what to write! How could that be admissable in a court of law?

They were aware that this cowboy operation existed out at the Bungles but once again NO ONE would do a thing to stop them...............

It took 2 yrs 7 mths after the accident for the inquest to be held and we did not get the final report until a further 6 months!! Over 3 years!!”

Then

“Well we had our inquest which was an absolute joke and embarrassment for the fact that so many documents were not produced / lost / created etc and no one did a thing about it. Our Coroner Ms Fricker left a lot to be desired and the fact that in the 2 years 7 months not one person in the court room excluding us had even visited the accident site or gone out to witness just what happens out there. We came away just blown away with the fact that so many things were dismissed/ allowed/undisclosed and were allowed to be.

That smell of money I think well and truly came into play!!!
I personally lost all respect for our government representatives, law, safety authorities after sitting in that court room for 5 days and listened to excuses on their behalf...instead of reasons to rectify and was horrified after the evidence given that it was declared and accident.

As I said in court this was an Accident waiting to happen and will occur again!!The coroner in her report even noted the number of helicopter accidents just since the inquest - approx 4 month....and not one recommendation was handed down. She used the words like Breached and Failed to comply in her report and yet not one
recommendation.”

Carolyn Cousins. (mother of Jessica Cousins) Slingair Robinson 44 Bungle Bungles 14

September 2008 4 fatalities

Although according to Beaker this accident was a high-energy impact:

Mr Dolan: There had been a number of post-crash fires associated with R44 helicopters. In the vast majority of those cases they represented high-energy impacts, which is to say accidents that were unlikely to have been survivable and which would have led to a post-crash fire in almost any helicopter.

Senator XENOPHON: So you are saying that the retrofitting would not have made any difference?

Mr Dolan: That would be our general assessment.

Senator XENOPHON: Take it on notice, because I have a few other matters to raise. You are saying that, from a causation point of view, even retrofitting the helicopters with that protective bladder, it still would have been a fatal accident?

Mr Dolan: On the facts that were available to us. We are not aware of any previous to Cessnock. I do not think we are aware of any of the low-energy collisions leading to that sort of thing. There were, as you say, a number of high-energy collisions that would have led to a ruptured fuel tank in any helicopter and therefore a great likelihood of a post-crash fire. Those are the sorts of accidents that generally are not survivable.

But on the evidence in the bureau report it would appear that there was a strong possibility the pilot at least survived the crash impact only to be overcome by the post impact fire, from the report:

Medical and pathological information
The post-mortem examinations for all occupants of the helicopter described varying degrees of injuries consistent with the high vertical velocity impact. All sustained extensive thermal injury.

The pilot’s post-mortem report indicated that he was found ‘...a slight distance from the damaged aircraft.’

You will notice that the post-mortem didn't appear to explore how the victims died i.e. did they succumb to their impact injuries or the 'extensive thermal injuries'. Nor was IMO the post-survivability issues properly explored by the ATSB. It was almost as if the ATSB accept that if a chopper comes (in particular a Robbo) down hard it will inevitably burn!

Yes 004 it will be interesting to watch and I bet there will be a couple of interested Senators tuned in as well..given the QONs outstanding on the subject of post-impact fires and R44s

Here's the links for the high energy post-impact fire fatalities to which Senator X refers:
http://www.atsb.gov.au/media/1533519/ao2008062.pdf

http://www.atsb.gov.au/media/1361537/aai...79_001.pdf

http://www.atsb.gov.au/media/24556/aair2...46_001.pdf

And here is a link for the report from the Jaspers Brush tragedy - AO-2012-021 - that included these two safety issues:

Fitment of rubber, bladder-type fuel tanks to R44 helicopters

And in ICAO Annex 13 Ch 6 under Safety  Recommendations  it is stated...

"..6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO..."

So what is the ATSB excuse for sitting on these SRs until now (over two years after the fact)?? No this is just another cynical attempt to gain credibility where none is due..
FFS get rid of the Muppet.    

   
Errr (grumble..grumble - ) - no comment!



MTF...P2

[Peetwo]

Real World vs The wizards of Oz aviation safety obfuscation -   

References from AP forum this week:

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 P2 comment - Read the Ben Cook PelAir Part 2 article here: The ditching of Australian aviation governance - Part 2

»» CASA’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
»» Consistent with widely agreed safety science principles, CASA’s approach to conducting surveillance of large charter and air ambulance operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the conduct of line operations (or ‘process in practice’).

Although there are pragmatic difficulties with interviewing line personnel and conducting product surveillance of some types of operations, such methods are necessary to ensure there is a balanced approach to surveillance, particularly until CASA can be confident that operators have mature safety management systems (SMSs) in place. [If CASA surveillance is too shallow how do more senior personnel (chief pilot, standards managers, check and training pilots) know whether their own practices are adequate and
aligned with best practice?]

Ultimately, inadequate regulatory oversight also contributed heavily to a false sense of security within Pel‑Air. How devastating it must have been post accident to have CASA inspectorate staff suddenly find so many systemic issues that had not been picked up during previous CASA surveillance.

Now watch again the '$89 million bucket' video (above). Anyone else get the impression there was no love lost between the former DAS McComic and BC 

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The theme for this week's SBG revolved around the Yin and Yang - or reality vs fantasy; black hats vs white hats - of the Australian aviation safety bureaucracy. This gives me the perfect opportunity to draw attention some excellent articles, tackling the closing of safety loops, from the real world of aviation safety; rather than the self-serving, 'BOLLOCKS' bureaucratic world of aviation safety administration in Sleepy Hollow, Can'tberra:

Irony is wasted on the stupid" | AuntyPru.com : Home of PAIN :

So first from AIN magazine:

AINsight: Rogue Pilots or Just Bad Procedures?
by Stuart “Kipp” Lau[/url]
 - June 22, 2018, 8:55 AM




Procedural noncompliance is a topic that gets a lot of attention. In most recent studies, much of the focus centers on pilots who intentionally deviate from a procedure because they are either too complacent, unprofessional, or worse, just bad apples.

The “fast thinker”—those seeking cognitive ease—might buy into this notion. For them, blaming an incident or accident on a “rogue” pilot is easy. Pilots should just follow the procedures and incidents and accidents won’t occur.

Their solution: remove that individual, issue a bulletin for the rest to “comply,” and the problem will go away, right?

The “slow thinker”—those wrestling with cognitive strain—will question the notion of a “rogue” pilot, understanding that complex issues don’t have one single solution, nor will they simply go away. The solution in this case might begin with identifying the human-factors issues associated with noncompliance and a healthy reflection on the procedures themselves. Line operations safety assessments (LOSA) studies suggest a high prevalence of noncompliance often points to an ineffective or bad procedure.  

At one time, procedural noncompliance was on the NTSB’s “Most Wanted List” and currently is a top safety issue for the NBAA Safety Committee. NBAA identifies procedural noncompliance as a significant contributing factor in aircraft accidents and incidents.

Furthermore, NBAA recommends, “Aviation professionals in all vocational categories must become aware of the extent that noncompliance has proliferated in business aviation, identify the causal factors for noncompliance and develop workable solutions that eliminate these events.”

Universally, it’s recognized that good procedures ensure standard pilot actions. Likewise, pilots adhering to good procedures enhance aviation safety. Thus, there’s typically a bad outcome when pilots intentionally don’t follow procedures. In fact, it’s a very slippery downward slope.

The LOSA Collaborative, founded by Dr. James Klinect, has more than 20,000 observations in its archive. This data shows that, on average, “Flights that have two or more intentional noncompliance errors have two to three times as many mismanaged threats, errors, and undesired aircraft states as compared to flights with zero intentional noncompliance errors.”

Intentional noncompliance by pilots might be more closely related to science than bad behavior. Some human-factors studies suggest that there are a number of issues related to a pilot becoming intentionally noncompliant. Often, these pilots, given a poorly written procedure, simply do not agree with the procedure and might believe their way is better—“an informed workaround.” Others might not fully understand a procedure or the risk associated with not complying. Additional factors such as fatigue can also play a role in intentional noncompliance.

Researchers also point toward three “perceived justifications” of being noncompliant: rewarding the violator (for example, “I get home earlier if I don’t go-around”); knowledge of associated risk (for example, “My risks are justified because I know better…”); or consideration of peer reaction (for example, “My reputation precedes me. I am a good pilot.”). The trick is to break these perceptions.

Organizations also have some culpability when it comes to procedural noncompliance. Operators must understand that there are indeed bad procedures. When it comes to developing and writing good procedures, words and actions matter.

Advisory Circular 120-71B provides some outstanding guidance on the design, development, and implementation of SOPs and checklists. It goes into great detail about the importance of providing flight crews background information on a new procedure or a change in existing procedure. Background helps a crew “buy into” the procedure by providing context and relevance.

According to the AC, implementation of any procedure is most effective when the procedure is appropriate for the situation; the procedure is practical to use; crewmembers understand the reasons for the procedure; pilot flying and pilot monitoring duties are clearly defined; effective training is conducted; adherence to standard is emphasized; and crewmembers understand the risk and hazards of not following the procedures.

For any developer or manual writer, this AC is a must. As an example, the use of ambiguous words—such as should or may—often leads a crew to noncompliance, by simply giving them an option not to comply.

The AC recommends the use of more positive words—such as do and must—since they are easier to read and less likely to be misunderstood.

Procedural noncompliance is a difficult issue to identify within an organization. LOSAs, when compared to the other voluntary safety programs, are one of the most effective tools to identify procedural noncompliance by highlighting areas where it is most prevalent. From those results, an organization can determine if it’s a pilot problem or organizational problem

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached via email.
[/size][/color]

Next from World renown Flight Instructor John (& Martha) King, where even Dick gets a mention... :

LET’S QUIT TALKING ABOUT SAFETY



Article appeared in Flying Magazine January 2018 by John King

“There can be no compromise with safety.” “Safety is our number one priority.” You hear these kinds of quotes all the time from well-meaning people—very often people like the Secretary of Transportation or the Administrator of the FAA. The assertions are meant to be comforting, and they are—especially after a crash. They assure the public of the firm resolve by people in power to do better. The problem is they aren’t, and can’t be, true.

You can’t start an engine without compromising safety. If safety were our number one priority, we’d never move an airplane. Clearly going somewhere is in itself a demonstration that moving the airplane ranks ahead of safety. It would always be safer to stay put. These little intellectual dishonesties tend to end discussion and substitute for genuine analysis on the subject.

It can be discomforting to talk openly and honestly about safety. So we often make false assurances and otherwise deceive ourselves. For instance, we usually talk about safety as if it were an absolute. But absolute safety is an impossibility. In reality, safety is relative. Every activity has a greater or lesser degree of risk associated with it. Still, when someone departs on a trip, we usually say, “Have a safe trip” as a polite expression of goodwill. We say this when we know having a genuinely safe trip is literally impossible.

Not only do we find it uncomfortable to admit to ourselves that we can never achieve absolute safety, but we sometimes utterly lie to ourselves in order to not have to face reality about safety. General aviation pilots used to frequently tell themselves, and their passengers, that the drive to the airport was the most dangerous part of the trip. They wanted to believe that flying their piston-engine general aviation airplane was safer than driving. When it became known that the fatality rate per mile in a general aviation airplane was seven times that of driving, they had a very hard time accepting that reality. (On the other hand, for various reasons travel on the airlines is in fact seven times safer than travel on the roads.)

Sometimes our self-deception on the subject of safety just reflects wishful thinking. After a series of commuter airline crashes, the Administrator of the FAA attempted to mandate one level of safety for little airplanes as well as big airplanes. The problem is that it is not possible for a small airplane to be as safe as a Boeing 747. Safety equipment is adds weight. A little airplane can’t carry the weight of the safety provisions of a 747. Plus, safety is expensive. A little airplane can’t afford the cost of safety equipment the way a bigger plane can. But who wants to tell that to someone about to fly in a smaller airplane?

On the other hand, when noted Australian thought-leader and avid pilot (weight-shift trikes, single-engine airplanes, helicopters, and jets) Dick Smith was Chairman of the Australian Civil Aviation Safety Authority, he steered people away from disingenuous talk about safety. He shocked people by talking about “affordable safety.” His point was that when safety becomes too expensive there can be a net reduction in safety. When excessively expensive safety measures are mandated, the cost of flying goes up. At some point people take less-safe surface transportation instead, and fatalities go up.

Another problem with the way we talk about safety has to do with how safety advice is normally given. It often provides very inadequate guidance. Safety advice usually takes a negative approach, stating what you cannot do rather than focusing on positive things you should do. In many cases it is limited to a hodgepodge of rules and sayings. The rules and sayings may all be good, but they are not adequate, because they fail to provide the big picture and structure.

Moreover, safety advice can even generate resistance. It can be preachy—taking on an off-putting air of smugness and superiority. It is not uncommon for advisors to suggest that someone does not exercise proper “judgment” or “aeronautical decision-making.” This comes across as a vague, demeaning criticism, but once again, with very little guidance.

So what is the alternative?

We need to change our vocabulary. In nearly every case, it is more insightful and helpful to talk about risk management. The concept of risk management suggests a proactive habit of identifying risks, assessing them, and exploring mitigation strategies for them. Those words “risk management” provide much-needed guidance about what people should do to get a safer outcome, in a way that the condescending criticisms, and emphasis on “safety,” do not.

One of the problems about the way we sometimes use the word “safety” is that if someone wants something done a certain way, they can often just simply trot out the word “safety,” or for that matter, “security,” and get carte blanche with little analysis. But the words “risk management” require a more thoughtful discussion—including in most cases identification and assessment of the risks and the appropriateness of the mitigation strategies.

When an aviation tragedy occurs, rather than trying to reassure and comfort people by promising things that are not possible, aviation leaders should say, “Our job is to understand the risk management failures that allowed this to happen and see that they do not occur again.”

Much to their credit, the FAA’s Flight Standards Service has embraced “risked-based decision-making” as one of its core values. The idea is that in this business of creating rules about how aviation should be run, they will now think in terms of the risks of an activity. Every safety measure has a trade-off in loss of fun and utility. When risked-based decision-making is a core value, that trade-off will be taken into consideration during rule-making.

The good news is that much of the aviation community is now focused on “risk management” rather than “safety.” First, flight schools are moving towards scenario-based training in order to help pilots learn risk management. The idea is to give a learning pilot the tools to habitually identify, assess, and mitigate risk. Then when that pilot is evaluated during the practical test, the FAA’s new Airman Certification Standards (ACS) require their risk management to be evaluated in every area of operation.

Martha and I have been promoting straight talk about safety for years. We finally figured we must be making progress when an attendee came up to us after a talk and said, “Have a relatively safe trip home.”[/size][/color]

 JK - Choccy frog is in the mail...  


MTF...P2 

[Peetwo]

For the record? 

As we all now know the ATSB in the course of the 1st PelAir cover-up investigation bizarrely decided, seemingly in contradiction to nearly all the principles of ICAO Annex 13, to not retrieve the CVR/FDR recorders from the wreck of VH-NGA (see above).

One of the lame arguments for not retrieving the boxes was that the CVR would only have covered the last 2 hrs of flight crew comms and radio calls, therefore would have been of limited value. What was never really touched on, was the over 100hrs of hugely invaluable data that was captured on the FDR. This data if properly analysed could have given an insight into such things as whether other aircrew operated VH-NGA in accordance/compliance with company SOPs and the CASA AOM. 

The following is an excellent NTSB blog that highlights how recorded flight data information can be instrumental in identifying and mitigating internal operator safety risk issues:

PART 135 FLIGHT DATA MONITORING: THE BEST WAY TO ENSURE PILOTS FLY SAFELY
JUNE 28, 2018 NTSBGOV LEAVE A COMMENT
By John DeLisi, Director, Office of Aviation Safety
 
On November 10, 2015, a Hawker 700A operating as a Part 135charter flight crashed on approach to Akron Fulton International Airport in Akron, Ohio. The crash killed 9 people. During our investigation, we learned that the first officer was flying the airplane, although it was company practice for the captain to fly charter flights. We also discovered that the crew did not complete the approach briefing or make the many callouts required during approach. Additionally, the flight crew did not configure the airplane properly, the approach was unstabilized, and the flight descended below the minimum descent altitude without the runway in sight.


NTSB investigators at the scene of the crash of a Hawker 125-700 into an apartment building in Akron, Ohio

How could this happen? Wasn’t the flight crew trained to follow standard operating procedures (SOPs)? (Yes, they were.) Didn’t they know when to lower the flaps? (Yes, they did.) Yet, weren’t they flying the airplane contrary to the way they were trained? (Yes, they were.)

The crew ignored, forgot, or improvised their company’s SOPs and the airplane’s flight manual information. Even more disconcerting was that, upon our review of the cockpit voice recorder (CVR), it appeared that this type of haphazard approach was fairly routine for them. How could that be?

The NTSB investigators discovered that no one at the company was monitoring—or had ever monitored—the way this crew flew the airplane. Because the airplane was not equipped with a flight data recorder, a quick access recorder, or any type of data monitoring device, the operator had no insight into what was happening inside the cockpit or how this crew was flying its airplane. The fact was that this crew was able to fly an airplane carrying passengers in an unsafe, noncompliant manner, which ultimately led to tragic consequences. If the operator had better insight into the behavior of its flight crew and had taken the appropriate actions, this accident may have been prevented.

That is a lesson learned the hard way—and we have seen similar such situations in several accidents the NTSB has investigated in recent years.
It’s time to be proactive about aviation safety and accident prevention! The NTSB believes flight data monitoring (FDM) programs for Part 135 operators—which includes charter flights, air tours, air ambulance flights, and cargo flights—is one answer to this problem.

An FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and can lead to mitigations that will prevent future accidents. Too many Part 135 operations occur in which the operator has no means to determine if the flight was being flown safely. An FDM program can help companies identify deficiencies early on and address patterns of nonstandard crew performance. Most importantly, with an FDM program, pilots will know that their performance is being monitored. As a result of the Akron investigation, the NTSB recommended that the Federal Aviation Administration (FAA) require all Part 135 operators to install flight data recording devices. But it’s not enough to just capture the data; we also recommend that operators establish an FDM program to use the data to correct unsafe practices. The FAA has yet to act.

But some Part 135 flight operators aren’t waiting for FAA mandates; they have already made the investment in such a proactive safety program—and with great success. One operator I read about started an FDM program recently and is having success using the data in a nonpunitive fashion to monitor approaches. With this critical data at its fingertips, the operator is attempting to identify instances of incorrect aircraft configuration or exceedances of stabilized approach parameters. Designated line pilots assess the data captured in the FDM program to determine if further follow up is needed.

Another Part 135 operator involved in an accident near Togiak, Alaska, investigated by the NTSB recently made the commitment to equip every airplane in its fleet with a flight data recorder. The operator told us the data will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.”


NTSB Member Earl F. Weener (center), Director of the Office of Aviation Safety, John DeLisi (right) and Loren Groff (left), Senior Research Analyst in the NTSB’s Office of Research and Engineering served as the board of inquiry for an investigative hearing held in Anchorage as part of the ongoing investigation of the crash of flight 3153 near Togiak, Alaska

Kudos to both these operators for learning from past lessons and committing to a culture of safety.

Last year, a Learjet that was being repositioned following a charter flight crashed on approach to an airport in Teterboro, New Jersey. Both crewmembers died. While the final NTSB report on this accident has not yet been released, our analysis of the CVR revealed that the first officer, who was not permitted by the company to fly the airplane, was, in fact, flying the airplane. During this flight, the captain was attempting to coach the first officer.

The first officer flew a circling approach; however, when the airplane was one mile from the runway, the circling maneuver had not yet begun. The first officer gave the controls to the captain, who proceeded to bank the airplane so steeply that the tower controller said the wings were “almost perpendicular to the ground” just prior to impact.

It comes as no surprise that the performance of this flight crew was not being monitored by any FDM program.

Isn’t it time to make passenger-flying operations safer? We see this type of program on major commercial Part 121 airlines, so why not on Part 135 aircraft? After all, flight data monitoring is the best way to ensure pilots are flying safely and passengers reach their destinations.

MTF...P2 

[Peetwo]

Aviation safety FAA style: 'Round up the usual suspects' - 

While on the world's most successful and statistically safest aviation system, the following is an excellent FAA flight safety initiative using the '50s movie classic Casablanca to help deliver the safety messages...    

"Round Up the Usual Suspects"
Corralling the Common Causes of GA Mishaps


by Susan Parson, FAA Safety Briefing

The mission of this publication is to be the FAA safety policy voice for non-commercial GA. We also aim to improve GA safety by making airmen aware of FAA resources, helping readers understand safety and regulatory issues, and encouraging continued training.

All those aims come together especially well in this issue of FAA Safety Briefing, which takes an admittedly whimsical and, we hope, engaging Casablanca-themed approach to addressing a deadly serious issue: the persistently consistent causes of GA safety mishaps.

Meet the Prime Suspects

The collection of common causes for GA accidents and incidents is remarkably (maybe depressingly) consistent. The AOPA Air Safety Institute’s most recent Joseph T. Nall Report notes that a whopping 75 percent of causes of non-commercial fixed-wing accidents can be attributed to the action — or inaction — of the pilot.

The mix of specific pilot problems shifts; just for example, the Nall Report notes that reductions in the number of takeoff/climb and adverse weather encounters were offset by increases in numbers attributed to low-altitude maneuvering, descent/approach, and (sigh) fuel mismanagement.

It is also troubling to note that instructional flights are again the second largest category for accidents involving personal flying. While the classic VFR-into-IMC scenario accounted for fewer than five percent of all accidents, these mishaps are deadly. Almost 70 percent of accidents in IMC were fatal, compared to 17 percent of those occurring in VMC.

Though not usually fatal, runway incursions are another elusive member of the not-so-exclusive usual suspects club for GA mishaps. FAA statistics (go.usa.gov/xQ8eN) show an uptick in national runway incursions as compared with 2017.

The numbers were better for non-commercial helicopter accidents (fatal accidents dropped by 30 percent), but low-altitude maneuvering persists as a leading cause.

Sleuthing for Solutions
We’ll take a look at each of these topics in this issue, all presented through the lens of famous phrases from Casablanca. But while we borrow the immortal “round ‘em up” words of Captain Louis Renault, Casablanca’sPrefect of Police, to talk about the causes, it’s important to emphasize that we don’t subscribe to his post-hoc, enforcement-centered methods of keeping order when it comes to airmen who make honest mistakes. Rather, as Flight Standards Executive Director John Duncan reminds us in this issue’s Jumpseat department, the FAA’s compliance philosophy aims at getting a steady flow of safety information we wouldn’t otherwise have. We then work collaboratively with airmen to prevent accidents from occurring in the first place or, if prevention isn’t possible, to keep them from re-occurring.

It’s Time

We know you’ve probably heard of all the usual suspects before, and you may even have more than a passing acquaintance with one or more of these pesky perpetrators. Safety-minded readers are similarly likely to be familiar with some — maybe all — of the suggested preventions and mitigations, so there may be more than a touch of the “can’t happen to me because I would never do that” mentality. However, somebody does keep falling prey to the pesky perps. So since nobody is immune from making honest mistakes and errors, everybody will benefit if anybody who encounters this issue will take the time to get a “safety booster shot” through reading and heeding the proffered preventions.


To encourage that investment of your time, we challenge you to keep a tally of all the Casablanca-inspired words and phrases in this issue — extra credit if you can identify both the source and the scene. Send us your best guess via the links in Forum or through our social media accounts, and we’ll recognize the winner in a future issue.

Are you ready?

Click the links under the images below to read the features!

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Master of My Fate: Maintaining Aircraft Control

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Is that My Runway? How to Avoid Wrong Surface Operations

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Maybe Not Today ... Avoiding the Perils (and Regrets) of VFR into IMC

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Not an Easy Day to Forget: Remembering Fuel Management Before It’s Too Late

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Thinking for Two: Managing Instructional Risk

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Learn More

• AOPA Air Safety Institute – 26th Annual Joseph T. Nall Report (PDF)
  
  
• FAA Runway Safety Information & Resources
  

Susan Parson (susan.parson@faa.gov, or @avi8rix for Twitter fans) is editor of FAA Safety Briefing. She is an active general aviation pilot and flight instructor.

This article was originally published in the July/August 2018 issue of FAA Safety Briefing magazine.

FAA Safety Briefing Webpage

MTF...P2 

[Peetwo]

Lessons of Flight 3407 not forgotten - 

While on the FAA theme I note the following tweet from Sully Sullenberger today:

 Sully Sullenberger‏ @Captsully
I join @3407Families in applauding Congress for passing this bill and leaving critically important pilot standards intact. There's no substitute for real-world pilot experience. @USDOT and @FAANews must continue to support upholding these vital standards. https://bit.ly/2NlGz1j 

---

Flight 3407 Families Applaud Passage of FAA Bill Upholding Stronger First Officer Experience Requirements

CONGRESS REBUFFS REGIONAL AIRLINES AND LOBBYISTS' ATTEMPTS TO WATER DOWN SAFETY STANDARDS

Buffalo, New York - October 3, 2018 - The 'Families of Continental Flight 3407' hailed today's passage of a five-year FAA Reauthorization Bill by the Senate that left intact stronger entry-level experience requirements for regional airline first officers. This safety initiative was the cornerstone provision of landmark aviation safety legislation unanimously enacted by Congress in 2010, and had been the subject of an aggressive and well-financed lobbying campaign by the nation's regional airlines and their lobbying arm that sought to relax its requirements.

"Kudos to Congress for recognizing what Captain Sullenberger and First Officer Skiles have been saying from Day One, that experience matters and these new safety requirements are working as intended," stated John Kausner of Clarence Center, New York, who lost his twenty-four year old daughter Ellyce when Flight 3407 crashed less than a mile from their family home. "We can’t say thank you enough to Senators Schumer and Gillibrand, as well as Senators Nelson and Cantwell on the Commerce Committee for fighting so hard to preserve these critical safety advances in the Senate. A special shout out as well to Senator Duckworth for her experience and passionate defense of these standards. On the House side, we had strong bipartisan support led by the Western New York delegation of Congressman Higgins, Reed, and Collins, and we also wish to recognize the T&I leadership of Congressmen Shuster, DeFazio, LoBiondo, and Larsen for ensuring that this issue never made it into the original House bill. Unfortunately we will never be able to bring my Elly back, but there is some solace knowing that the skies are safer for someone else’s daughter. Now perhaps the airlines can scale back their lobbying budgets so they won’t have to keep raising their baggage fees.”

In the midst of the regional airlines’ push to relax the safety guidelines, the family group continued to point to the regionals’ sterling safety record in the aftermath of the crash and the subsequent legislative and regulatory initiatives. They have led to over nine years without a fatal commercial crash, the longest such period in American history by over three times.

“People can debate the optimum preparation for a pilot all that they want, but the bottom line is that what we have in place is working, and just as importantly, it is making it harder for the shortcut-takers like Colgan and Great Lakes to stay in the game,” stated Scott Maurer of Palmetto, Florida, who lost his thirty-year-old daughter Lorin. “Now that the regionals have hit a dead end in Congress, it is only logical to expect them to go to the Administration directly for a bailout. However, both Secretary Chao and acting Administrator Elwell have made it very clear that they would only take such action if directed to do so by Congress. We are taking both of them at their word, and now we look forward to working with their agencies to bring the Pilot Record Database project to completion. This is another critical step to ensuring that the extremely preventable mistakes that led to the crash of Flight 3407 are never allowed to repeat themselves. As we look ahead to the next Congress, we will continue to remain vigilant and vocal.”

 
MTF...P2 

[Choppagirl]

Strange thing is; the same manager was in charge of both Canley Vale and Pel Air investigations; both have serious question marks over the CASA involvement and ATSB ‘reporting’.

Even stranger is the latest rumour that the same person is reported as saying publicly the Rev. Forsyth was either bullied, brainwashed, seduced or coerced into writing a defamatory, scurrilous, untruthful report and providing it to the minister; even thinks the good Rev. should be prosecuted.  All unfounded rumour of course, but even so, it's all passing strange, don’t you think?

But, I do know who I’d believe, if push ever came to shove.

I wonder what the initials are of this person? Is one of them D??

"K' - All here:-

[Kharon]

Safety Loop or Hangman’s noose?

Cheers P2; this has been coming for a while now and is well over due. Sen. Fawcett tried to get the ball rolling in the right direction way back in 2012, yet seven years later the core subject matter has not been properly addressed in a positive or even a satisfactory fashion.

We did do an abridged version of the analysis we ran – HERE – but – as I recall we left it on the shelf after while when the promised legislation and amendments failed to materialise (as per usual). There is a long list of them; and all that seems to have surfaced is more ways to allocate blame, but little in the way of ‘preventing’ a reoccurrence. The same ‘accident’ has been claiming lives for quite a while, clearly demonstrating that ‘rules’, no matter how complex, simply are not preventing repeat accidents.

16/10/2012 - Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we spoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.

Fawcett, with a flick of his wrist has unveiled the Elephant in the room. It is a simple concept which, IMO the departments involved have been at some pains to avoid acknowledging. The construct is a simple one:- (a) there has been a fatal; (b) ATSB have, best they may defined the nature of it; © there is a Coroners court; (d) the Coroner makes recommendations and hands down his findings; (e) nothing further happens – in real terms.

ATSB sit on their hands: they have put forward their recommendations.
Coroner moves on to the next case – job done.
CASA adopt their standard plan, dismiss recommendation as opinion, tell the ATSB to bugger off and life rolls on as though nothing happened; except the liability and ‘blame’ game continues unabated.

Visual flight into instrument conditions is an old killer. There are remedies, but for every remedy the is a stone wall built to prevent CASA from making the commitment to change. The Private IFR rating – graduated approval – all too hard for CASA – they may have to answer questions. It is easier to say NO than it is to expose the lack of operational safety expertise needed to make such a scheme a winner.

Flight in Night Visual conditions is another area which has claimed many lives. It is not inherently dangerous, but it is an operational flight discipline which demands care and  training. Experienced pilots as well new chums get into strife as the data shows. Once again remedies are available; once again CASA needs the sorely lacking imagination and operational experience to apply a cure.

The damn shame is that there is, within industry, a wealth of operational and technical expertise which CASA could call on to assist develop ‘ways and means’. Alas, even Senate Committee and independent report recommendations are dismissed as merely the ‘opinions’ of the Ills of Society; or, of folk who don’t understand that the mystique of aviation safety is worth squillions to those who frequent the CASA top table trough.

We are in desperate need of a Minister who is not captured, hypnotised or baffled by the mystique and unconcerned about the blood being on ministerial hands. Fat chance – right.

Toot – toot.

[Peetwo]

Aviation safety and the rule of three?

Quoted extracts from THIS (must read) Clinton McKenzie post off the UP:

...There’s an irony here: My ‘day job’ is administrative law and, accordingly, AAT and other other administrative law proceedings are mundane for me. I also have some insight into the detail of the aviation law. But it is because of my expertise and experience that I find dealing with Avmed’s bullshit so stressful. It’s like entering a parallel universe in which objective evidence, objective risk, disinterested decision-making and legal principle go out the window, simply through invocation of “the safety of air navigation”...

...It is bad enough that millions continue to be wasted on the never-ending aviation regulatory ‘reform’ dog’s breakfast that produces ever more complexity with little-to-no positively causal improvement in aviation safety in return for the cost. But millions are also now wasted on the peddling of dangerous operational folklore as well as what I consider to be the safety-inimical activities of Avmed. 


It’s broken. I hope against hope that it won’t take a disaster for it to be fixed...

 
Hmm...perhaps we - the BRB, the IOS, Senator Fawcett etc..etc - have all got it wrong and the 'safety loop' has already been closed by the aviation safety bureaucracy; closed to any and all outside contribution or involvement in the risk mitigation of identified significant/critical safety issues?       

Speaking of closed loops (or if you prefer Hangman's nooses) we have a perfect parallel between the real world of international aviation safety and the ticking time bomb fantasy world of Iron Ring enforced aviation safety.

To begin let's set the scene with these references courtesy of the '2019 and the Election thread'  :

...I wonder, will any of our potential Ministerial wanabee’s deeply embroiled in attempting to be elected take the time to consider the accident in Moscow and draw the comparisons. If they do happen to notice it, perhaps the message from this event should be taken to heart and something done about the Australian situation. Our Rescue and Firefighting (RFFS) experts have been warning the government that through ASA’s efforts to pay for the One-Sky monster, the parsimony and KPI driven result is placing lives at risk.  A rare event in Moscow; but, not the first this decade, nor is it likely to be the last. It happens, it’s real and people die.

"Concerns were also raised about the length of time taken for fire crews to appear on the scene, with experts describing the response at Moscow’s largest airport as “extraordinarily poor”

There may well be several good reasons why the Moscow RFFS turned out late – we need to wait for the report; but one thing is certain sure, it was not the local fire brigade who had to wade through 10 K of city traffic to get to the accident.

"Veteran aviation commentator Neil Hansford said once a mayday was called, as in this instance, firefighters should have been mobilised. “It looks like they hadn’t even left the fire station when the plane touched down,” he said.

Here again – we need the report -

“although some Russian reports blamed a lightning strike for disabling radio communications and prompting the return to Sheremetyevo.”

Too much to speculate on – however, the salutary lesson for government is a simple reality fix:-

“It took 45-minutes for the fire to be extinguished, not helped by the large amount of fuel on board for the 2½ hour-flight to Murmansk.”

How much longer can the Halfwit’s luck hold out and who will be in the ministerial hot seat when Australia looses one at Mildura, in the fog, with no RFFS on site until 15 minutes after the fireball. Food for thought ain’t it.

P2 addition: via https://simpleflying.com/aeroflot-crash/  

...One thing that strikes as surprising is that the fire crew seem to have a fairly long response time to reach the aircraft. Given that the aircraft was squawking 7700 prior to landing, one would assume that the fire crew would already have been en route to respond in a ‘just in case’ capacity. This is often the case when an aircraft lands after declaring an emergency. Instead, all the footage shows that at least 60 seconds after the aircraft came to a halt, the fire service was still not in attendance...

Ref: RFFS Inquiry Update - BrisVegas Hancox opening statement etc. 

The Devil’s Advocate –

In defence of the Moscow RFFS; more in hope that ‘the media’ may take a more balanced, intelligent look at aircraft accidents. Why? – Well grounded media reports could greatly assist the Australian governments see the need to listen to; and, act on the expert advice our own excellent RFFS offer. The following paragraph being a good example of the ‘short fall’ which IMO trivialises the enormous difficulties of ‘saving lives’ after an event has occurred.

“As a result, the main landing gear collapsed and the fuel tanks ruptured, leaving the aeroplane to careen off the runway on its nose gear and engines, resulting in a massive fire.”

The optimum time to ‘save lives’ was as soon as possible after the fire started – if not before. Had the aircraft simply ‘collapsed in a smoking heap on the runway – before the fire took hold – it is a good bet that the survival rate would have been 100%. This did not happen – what we see is a very heavy machine, at speed careering along the ground – ‘on fire’. There is not anywhere on this planet a RFFS service which could do anything – at all – to assist. As the aircraft slowed (ground) to a halt, the optimum time for saving life was reduced by a considerable margin; the situation as dangerous to rescue crew as to the passengers.

When an aircraft has a ‘problem’ which requires a return to land – a.s.a.p. the flight crew have options – “Mayday” requires no explanation: a PAN call whilst serious triggers a less intense response – maybe even the question from the ground – ‘do you require services’ if the crew have not requested the services required (routine SOP). Watch any of the video of aircraft in trouble and you will see the first response RFFS lined up ready to do their jobs once the aircraft comes to rest; they even ‘chase’ the aircraft to the end of the ground roll, so as to get busy at the first opportunity.  Provided the RFFS is on site and fit for purpose – any purpose necessary. This cannot happen if the required men (and women) are not ‘on-deck’ and trained. This cannot happen if those men and women do not have the equipment to do their dangerous, life saving work.

Air Services Australia (ASA) are required to ensure that these services are available. ASA are a monopoly, they make a profit. The top layers have KPI and bonus; there is no incentive to reinvest in the service – by turning a profit (and bonus) into a loss and seeking additional funds to properly acquit their responsibility.

The Moscow scenario could happen at any aerodrome in Australia any tick of the clock; think Mildura fog. What if one of those aircraft had a main gear collapse? What if one of those aircraft had a heavy landing and ran off the runway? Who would be there to assist? The short answer is no one – no one to dog the aircraft until it was safely off the runway. The Australian travelling public are travelling on pure luck once they leave a major airport for a regional centre. The RFFS services have been warning the government about the situation. – Perhaps, it’s time the government listened to the experts, not the Halfwits who work on ‘statistics’ instead of counting the ultimate cost in flesh and blood burning to death in fire.

It would be great if a journalist could do an expose on the warnings issued to a string of ministers; the lack of equipment and the ‘system’ in place for RFFS at regional destinations; said Journalist could even throw in the lip service paid to and the obfuscation of the obligations Australia has under the ICAO agreement.

And now courtesy of Byron Bailey, via the Oz today: 

 

Pilot skills go missing in modern flight-mares

In days of yore when men actually manually flew aircraft, a term called piloting, a common phrase was “there is no substitute for experience”.

Just like in the shipping arena, a captain had to earn his stripes.

Enter automation, which has now reduced the pilot’s role to flight deck manager.

This is fine when things work as advertised, and modern aircraft are exceedingly safe, or so we thought until Boeing literally dropped the ball with the 737 MAX 8.

The pilot’s role has so diminished and manual flying skills and knowledge have been so reduced that pilots with only several hundred hours total flying experience can now occupy a control seat.

As long as they can program the flight management computer that is deemed satisfactory, especially to the bean counters that run airlines. But what happens in the rare cases where an abnormal problem occurs and the crew have to rely on old-fashioned flying skills?

Three very recent accidents are cases in point.

The Aeroflot Sukhoi Superjet-100 landing crash in Moscow was a very disturbing illustration of a pilot not handling the situation.

This modern aircraft had a problem but flew for 27 minutes. This obviously was not a time-critical situation, so the crew should have assessed the situation, run checklists, dumped fuel, notified air traffic control so RFF (rescue fire facilities) were on standby and then proceeded with as normal an approach and landing as possible.

Instead, the almost panicked crew had to go around off the first approach because they turned in too tight on a runway base turn. On the second attempt the video shows they were way too fast and slammed the aircraft on to the runway and bounced. The second hard impact caused the landing gear to collapse and puncture the wing fuel tanks. The resulting conflagration of 14,000 litres consumed the rear fuselage such that 40 of the 73 passengers on board plus one of the five crew died. More may have managed to escape except that some passengers took time to retrieve large baggage from the overhead lockers. The International Civil Aviation Organisation and International Air Transportation Association urgently need to address this problem.

Last week a B737-800, operated by a Miami charter company on a military contract, had a landing overrun by 1200 feet into a shallow lake. All survived. This was not only an example of very poor manual flying skills but stupidity as well.

This particular B737 had one thrust reverser unserviceable but was permitted to operate under a MEL (minimum equipment list) for a certain number of flights. The pilots therefore were aware of an effect on landing distance.

The pilots chose to land on the shorter 8000-feet runway when there was a 9000-feet runway available that was more into the wind. They touched down at an IAS (indicated airspeed) of 163 knots (about 20 knots too fast) and, with a tailwind of 15 knots, that meant a groundspeed of 178 knots. What the hell were they thinking? The flight envelope limit is 10 knots tailwind on landing, so they should have aborted the landing.

The 178 knots kinetic energy, with probable considerable float due to the excessive speed, meant the brakes had no chance to pull the aircraft up before running off the runway. This was a major RPE (resume producing event). It is well known that charter operators use pilots gaining experience before being employed by the major airlines.

The third accident is the disappearance of a large Challenger private jet out of Las Vegas for Mexico while avoiding thunderstorms. I have been flying a Challenger for the past nine years. To operate, they are just like an airliner with good weather radar and solid safe flying characteristics. Suggests to me perhaps inexperience in use of the weather radar.

The industry is at a tipping point. When I learnt to fly in the air force the two major subjects were aerodynamics and airmanship. These appear to have been replaced by psychobabble subjects and computer knowledge. Flight deck etiquette should not be more important than the ability to fly the aircraft and make correct rational decisions.

With all of the above in mind, spot the disconnected dots with the Iron Ring's version of Alice in Wonderland...

...Starting with Robyn Ironside, via the Oz:

Airports to trial new time-saving emergency response system


Airservices Australia is about to trial a new way of alerting airport firefighters to aircraft in trouble, in an effort to reduce response times to under three minutes.

In a week when emergency response times to aircraft disasters has been in the spotlight as a result of the Aeroflot tragedy in Moscow, Airservices has revealed it is working to improve on the two to three-minute “best practice” industry benchmark.

Melbourne and Launceston airports will be the first to trial the system, whereby the air traffic control tower directly dispatches fire crews to emergencies.

Airservices executive general manager of aviation rescue and fire fighting, Rob Porter, said the current process involved an exchange of information between the air traffic controller and fire control centre operator that could use up valuable seconds.

“Either the controller contacts the fire control centre operator and explains what the situation is, or the operator sees an incident and contacts the tower to get more information,” Mr Porter said.

“We’re looking at a way to improve our response times by (firefighters) being directly responded by the tower.”

He said the new system being trialled would not increase the responsibilities of the air traffic controller or undermine the authority of the fire control centre operator.

“(ATC) is already passing information on to us, so the task is the same,” Mr Porter said.

“But I have to emphasise this is a trial, this is something we believe will improve our response times.”

United Firefighters Union Australia aviation branch secretary Mark von Nida said he had no objections to ATC having the ability to dispatch fire crews to runway emergencies.

But he was concerned about anything that downgraded the role of the fire control centre operator who was trained to look for potential risks to safety.

“Every second counts in aviation rescue, that’s the whole concept of the fire control centre guy watching every take-off and landing with a pair of binoculars,” Mr von Nida said.

“He can see any sort of problem — if there’s a bit of smoke on landing, he can follow that all the way back into the apron to make sure it doesn’t catch on fire.

“Up to about 30 minutes after an aeroplane lands, heat can still be building up so it’s not just a matter of when it touches down.”

However, Mr Porter said responding to aircraft incidents was only one of the tasks the fire control centre operator had. “They are at the core of the operational communications for that fire ­station, so they’ve got other functions they need to do: monitoring fire alarms, taking phone calls, responding to first aid responses,” he said.

“They have a very important role and this (trial) is not a cost-saving measure, it’s actually an ­efficiency measure.”

Mr von Nida also raised concerns about the new fire station at Brisbane Airport having no direct line of sight to the new parallel runway.

He said the site chosen for the station seemed completely unsuitable for the role firefighters were expected to perform. Mr Porter said CCTV cameras would address those issues, allowing firefighters to see all the runway ­activity.

The provision of rescue, firefighting and emergency response at Australian airports was under examination by the Senate Committee for Rural and Regional ­Affairs and Transport prior to the federal election being called.

It is expected to resume after the next government is installed later this month.

The trial of the new emergency response alert system at Melbourne and Launceston airports would begin later this month, Mr Porter said.

Hmm...and from Senate Estimates :

CHAIR: How long do you think it was yourselves? The alarm went off out in the tea room. We've hit the number. We're now obliged, or prescriptively obliged, to go ahead and stand up the service. From that day until you turn the lights on, how long do you think it is?

Mr Harfield : Off the top of my head I think the period that we've got is about three years.

CHAIR: Does that not seem to you to be a long time to do that?

Senator PATRICK: Particularly when safety's the name of the game. We always hear people talking about safety. We've now got an airport with a fairly significant number of passenger movements but no fire services.

Mr Harfield : I need to outlay the alternative work on not just building the fire station but the work that we've done with the local fire brigade and the work that we've done ensuring that we try to manage—

CHAIR: I think we can all imagine what needs to happen. I mean it's not an easy thing. You have got to design a building and find a space at the airport. It's got to meet all the criteria. You've got to find expert people to go and occupy it—we get all of that, and no-one's suggesting that you can blow it out on Tuesday over the weekend.

Senator PATRICK: But it's reasonable to assume, Chair, that they would have done it before. It's not new to them.

CHAIR: That's right. You haven't been caught short, but three years? That seems to me to be an inordinately long period of time, particularly for Proserpine. It's not as if you're building the Taj Mahal to house 100 trucks or something. And I come from this world: I know how long it takes from an idea until you go and get some approvals, build a building and buy a truck and park it in there with a competent driver. I'll leave it up to Senator Patrick to pursue it, and I don't know whether I speak for the committee but you need to go and have a real reflection on this. This is too long in my view.

Senator PATRICK: Can you also look back at the previous, say, two or three fire stations that you set up. I just want to get a comparison of what you've done previously. Because I'll tell you: it was put to us that there was a review underway about what that number should be—whether or not it should go to 500,000—before the trigger commenced; I'm pretty sure that was right, wasn't it?

Mr Harfield : There was talk about going to 500,000 as risk based.

Senator PATRICK: That's right, and so I just wonder how much people held off for the fact that we might just wait for this review to kick in and that maybe we don't have to do it.

Mr Harfield : I can say that that's not the case because the regulations were 350,000.

Senator PATRICK: No, and I made the point at the hearing: you don't have a choice—you don't get to sit and say, 'I've heard the speed limit might be going down to whatever, therefore I'll drive at this speed.'

Mr Harfield : Correct. We have to deal with the rules and regulations that are in front of us.

Senator PATRICK: But there are times when government can act really quickly and times when government can act quite slowly. Can you provide a comparison of the previous three fire stations that you stood up; when it hit the trigger; and how long it took to stand up the service.

CHAIR: Do you agree with the observations, Mr Harfield, because right now I don't get a sense from the three of you as to whether you think that we're being unreasonable with this reflection on three years. And if you go away from here thinking, 'Oh, they just don't understand. It's tough, and it'll always be three years,' that doesn't help. We're asking you to defend the three years if you want to. You must know what's involved. You must know what takes that long. You've done it frequently enough. Or give us some positive indication that: 'We might go and look at this. We may have to change our task register so we start to get some things done at the one time.' Do you find three years an inordinate amount of time?

Mr Harfield : Senator, yes I do. The point you just made is that we'll go back and look at the safety case that we submitted and was approved by CASA which outlined the time frames of putting in this particular service. We'll have a look to see whether we can make it—

Or in pictures from about 6 minutes:

Hmmm...on the bona fides of the pencil headed Mr Porter - remember this?

 
And from about the following (quoted Hansard - HERE - point) recorded from the BrisVegas RFFS Senate Inquiry public hearing:

...Senator O'SULLIVAN: I'm testing their level of happiness or unhappiness. I'm asking you: within your scope of knowledge, was it the case during this consultation process that the men and women who have to discharge the duties associated with this were unhappy about the site location?

Mr Porter : All I can say is that the location has to meet the regulatory requirements. I can't gauge whether—

CHAIR: Don't do it to him!

Senator O'SULLIVAN: I'll tell you what, we don't have to pull the shades down, because we can sit here until it goes dark outside. Mr Porter, let me put the question to you one more time, slowly: within your scope of knowledge, was it the case that the men and women representing the professionals in the consultation process you referred to indicated that they did not agree with the selected location for the establishment, the construction, of this new station?

Mr Porter : I think it's fair to say that there were some who were happy and there were some who weren't happy...

---

&..

..Mr Porter : I'm not sure on the air traffic controller roles at all.

Senator O'SULLIVAN: This is probably one of the most important functions that you have in your roles and responsibilities. I recommend you pay them a visit soon to answer these questions. Imagine this now: I'm governing this plane in the air until it lands, but my companion here, who's off getting a cup of coffee, is responsible for observing it from a safety point of view. That's what I want to know. You can take that question on notice. I'll be surprised, Mr Porter, if it's not the same individual. When it lands, I know that Observer Sterle has now got control of that aircraft; if I see it burst into flames, I don't have to worry about it, because I know Sterle's going to notify, 'Mayday, mayday, mayday'. Is that your understanding of it?

Mr Porter : That would be my understanding, but, again, I'll take it on notice.

Senator O'SULLIVAN: You seriously need to have a look at this in your position...

 
Hmm...notice how Mr Porter takes a lot of things on notice?



Do you reckon he'll taking it on notice if (God forbid) something like the above occurs at Proserpine or Essendon in say the next twelve months?
 

MTF...P2 

[Peetwo]

Open safety loops in another hemisphere?? 

Have been monitoring the progress of the NTSB AAI into the tragic in-flight collision between a float-equipped de Havilland DHC-2 Beaver and a float-equipped de Havilland DHC-3 Turbine Otter that resulted in six deaths (one of which was a Sydney businessman) and nine serious injuries.  

Here is the media release which accompanied the NTSB 22 May 2019 preliminary report:

NTSB Publishes Preliminary Report for Investigation of Mid-Air Collision, Calls for Greater Safety Measures for For-Hire Flights

5/22/2019

The National Transportation Safety Board Wednesday released the preliminary report for its investigation of the May 13, 2019, fatal mid-air collision near Ketchikan, Alaska, one in a string of recent accidents involving for-hire aircraft.

The collision between a float-equipped de Havilland DHC-2 Beaver and a float-equipped de Havilland DHC-3 Turbine Otter occurred about seven miles northeast of Ketchikan, Alaska. The DHC-2 commercial pilot and four passengers sustained fatal injuries and the DHC-3 certificated airline transport pilot sustained minor injuries, nine passengers sustained serious injuries and one passenger sustained fatal injuries.

Both aircraft involved in the mid-air collision were operating under Part 135 of FAA regulations, which govern the operation of business and charter flights. So was the airplane that crashed Monday in Alaska and the helicopter that crashed in Hawaii April 29.

“While these tragic accidents are still under investigation, and no findings or causes have been determined, each crash underscores the urgency of improving the safety of charter flights by implementing existing NTSB safety recommendations,” said Robert L. Sumwalt, Chairman of the National Transportation Safety Board. “The need for those improvements is why the NTSB put Part 135 aircraft flight operations on the 2019 – 2020 Most Wanted List of transportation safety improvements.”

The NTSB’s safety recommendations call on Part 135 operators to implement safety management systems, record and analyze flight data, and ensure pilots receive controlled-flight-into-terrain avoidance training. Major passenger airlines, which operate under Part 121, have adopted these measures and have seen a great improvement in safety.

“A customer who pays for a ticket should trust that the operator is using the industry’s best practices when it comes to safety,’’ Sumwalt said. “And it shouldn’t matter if the operator has one airplane or 100. Travelers should have an equivalent level of safety regardless of the nature of the flight for which they paid.”

The preliminary report on the investigation of the May 13 mid-air collision does not discuss probable cause. The report contains information gathered thus far in the investigation.  Determination of probable cause and the issuance of any safety recommendations comes at the end of an investigation. Investigations involving fatalities and other major NTSB investigations currently take between 12 and 24 months to complete.

The preliminary report for the Ketchikan crash is available on the NTSB website at https://go.usa.gov/xmfmQ .

The preliminary report for the April 29, helicopter crash near Kailua, Hawaii, is available on the NTSB website at https://go.usa.gov/xmf8G .

The preliminary report for the Metlakatla crash has not yet been developed.

To learn more about the NTSB’s Most Wanted List and Part 135 aircraft operations visit https://go.usa.gov/xmf8M.

---

 Improve the Safety of Part 135 Aircraft Flight Operations



Regardless of the purpose of the flight or the type of aircraft, all flights should be safe—right now they may not be. That’s because the Federal Aviation Administration (FAA) doesn’t require air medical service, air taxi, charter, or on-demand flights to meet the same safety requirements as commercial airlines.

Part 135 operators must implement safety management systems that include a flight data monitoring program, and they should mandate controlled flight-into-terrain-avoidance training that addresses current terrain-avoidance warning system technologies.

Ignoring safety recommendations - now where have I heard that before...  Oh well at least the NTSB is not afraid to issue a safety recommendation - FFS! 

Here is the Google media image search link - HERE - which links to some very vocal (not scared of their own shadow) MSM coverage...  

 

Hmm I wonder...given the Ketchikan accident included an Australian citizen and given that CASA will be introducing their bastardised version of the FAR Part 135 in 2021, has the ATSB nominated an accredited representative to this NTSB AAI? 

MTF...P2 

[Peetwo]

Qantas - A loop that definitely needs closing?

I note today this from AJ?? 

https://www.abc.net.au/news/2021-07-22/q.../100313718

..Qantas chief executive Alan Joyce has warned staff to brace for the potential of renewed stand downs, as closed borders and lockdowns smash domestic travel... 

Hmm...QON: Are we perhaps seeing the resultant impact of sustained unprofitability within the Red Rat?

ATSB to investigate if Qantas crew forgot to raise landing gear on take off



An investigation has begun into the second Qantas flight in less than a month to have a landing gear oversight.

On July 12, a QantasLink Dash-8 took off from Sydney to fly to Albury, but it was not until the aircraft was well into the climb that the crew realised they had not retracted the landing gear.

The wheels were brought up without incident but because the chain of events was outside standard operating procedure, the crew returned to Sydney, landing an hour after take off.

As well as the Australian Transport Safety Bureau investigation, a Qantas spokeswoman said an internal review was underway to understand why the landing gear wasn’t retracted.

“We will work with the ATSB on its investigation,” said the spokeswoman.

It’s believed there were no maintenance concerns with the aircraft and human error was considered the most likely reason for the issue.

The ATSB investigation summary said the flight crew would be interviewed and operator procedures and flight crew records reviewed, along with recorded data.

The incident came just three weeks after another landing gear issue, involving a Qantas 787-9, flying from Sydney to Perth.

On that occasion the crew was unable to retract the wheels after take off and returned to Sydney Airport for an engineering inspection.

It was then discovered that the locking pins had not been removed from the main landing gear prior to the flight.

Ref: https://www.atsb.gov.au/publications/inv...-2021-028/

The ATSB is investigating an incorrect configuration involving Bombardier DHC-8-400, registered VH-QOY, near Sydney Airport, New South Wales, on 12 July 2021.

After take-off, the flight crew did not retract the landing gear. This was not identified during the after take-off checks but discovered later during the climb. After confirming it was safe to do so, the flight crew retracted the landing gear and returned the aircraft to Sydney.

The evidence collection phase of the investigation will include interviewing the flight crew and reviewing operator procedures, flight crew records and recorded data.

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

---

Qantas ‘wheels down’ flight under investigation



An investigation is underway into why a Qantas 787 took off with the locking pins still in the main landing gear, which meant the pilots were unable to retract the wheels.

The incident happened on June 21 at Sydney Airport, as the aeroplane took off for a five-hour flight to Perth.

According to the Australian Transport Safety Bureau, the aircrew realised there was a problem when they could not retract the main landing gear and received a “gear disagree” message.

Within 45-minutes of takeoff, the crew returned to Sydney for an uneventful landing and engineers inspected the Boeing 787-9.

“The engineering inspection revealed that the forward gear pins on the left and right main landing gear were not removed prior to the flight,” said the ATSB investigation summary.

Normally pre-flight inspections by engineers and the captain would ensure the gear pins were removed.

The pins are inserted when an aircraft is on the ground at airports to prevent any inadvertent collapse of the landing gear.

Although Qantas denied there was ever any threat to safety, a spokesman said the incident was

being taken seriously.

“There are checks to in place to ensure these locking pins are removed before each flight and we’re looking into why this did not occur on this occasion,” said the spokesman.

Ref: https://www.atsb.gov.au/publications/inv...-2021-028/

The ATSB has commenced a transport safety investigation into a landing gear indication involving a Boeing 787, VH-ZNH, near Sydney Airport, NSW, on 21 June 2021.

During climb, the main landing gear did not retract and the crew received a gear disagree EICAS message. The crew returned the aircraft to Sydney for an uneventful landing. The engineering inspection revealed that the forward gear pins on the left and right main landing gear were not removed prior to the flight.

The evidence collection phase of the investigation will include a review and examination of maintenance records and the gathering of any other relevant evidence. 

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

MTF...P2 

[Peetwo]

Vic Coroners Essendon DFO crash inquest begins - 

Via the MSM:

1. Fiery Essendon DFO plane crash pilot Max Quartermain failed key test two years before fatal crash

2. Pilot Max Quartermain failed a key skills test two years before deadly Essendon DFO crash, court hears
 
3.

Essendon DFO crash pilot failed test before fatal flight

By Erin Pearson
September 21, 2021 — 6.03pm

A pilot who died in a plane crash that killed his four passengers near Essendon Airport in 2017 had failed an in-air competency test before the fatal flight, after being involved in a near-miss while carrying passengers over Mount Hotham two years before.

Following the near-miss in 2015, pilot Max Quartermain took part in an instrument-proficiency check alongside Civil Aviation Safety Authority inspector Naomichi Nishizawa.


The aircraft crashed into the DFO shopping centre seconds after taking off from Essendon Airport.CREDIT:SEVEN

A coronial inquest into the Essendon Airport deaths heard on Tuesday that Mr Quartermain appeared stressed during the test in October 2015, and mixed up mechanical instruments during an in-air engine failure simulation, causing the CASA operator to terminate the assessment.

The inquest heard the 63-year-old then failed to undertake a six-month proficiency check. A series of non-compliance notices were issued over the following year after it was determined Mr Quartermain lacked some knowledge.

Mr Nishizawa told the inquest that after that initial test, he made a suggestion that Mr Quartermain undertake remedial training to “address areas of his shortfalling” before a future proficiency check. But he told the coroner CASA had no power to mandate that training.

He later passed Mr Quartermain. He told the Coroners Court everyone has their “good and bad” days.


Four victims of the plane crash: Pilot Max Quartermain and golfers Russell Munsch, Glenn Garland and Greg De Haven.

When asked whether CASA had the power to suspend, vary or cancel the pilot’s licence after such a “major failure” during the instrument-review flight, Mr Nishizawa said he believed Mr Quartermain was still in shock from the Mount Hotham incident a month earlier and any changes to his licence would have been “premature”.

Less than 18 months later, on February 21, 2017, Mr Quartermain was at the helm of a Beechcraft B200 King Air plane, bound for Tasmania, when it crashed into the DFO shopping centre seconds after taking off from Essendon Airport.

Mr Quartermain was killed in the crash, along with American tourists Greg De Haven, Glenn Garland, Russell Munsch and John Washburn, who were flying to King Island to play golf.

---

How the Essendon DFO plane crash happened


Graphic: Jamie Brown

---

A subsequent Australian Transport Safety Bureau review found the aircraft’s rudder trim was in a full nose-left position during take-off.

The final aviation safety report into the 2017 crash is expected to be publicly examined for the first time as part of the inquest. How the rudder came to be in that position is also expected to be explored.

On Tuesday, the inquest heard Mr Quartermain was stressed at the time of his 2015 in-air instrument-proficiency check because he was facing difficulty ensuring the continued operation of the B200 aircraft after the owner allegedly lost interest in keeping it flying under his certificate.

The inquest continues on Wednesday.

P2 comment - Although the focus of the inquest seems to be initially on the previous Mt Hotham loss of situational awareness incident (ref: Near-collision and operational event involving Beech Aircraft Corp. B200, VH-OWN and VH-LQR, Mount Hotham, Victoria on 3 September 2015 ) and the subsequent failed IPC which was conducted by CASA Flight Examiner/FOI Naomichi Nishizawa, it is worth noting that the weather was CAVOK, the pilot was conducting a standard visual departure and throughout the crash sequence the aircraft never entered IMC. Combine that with the pilot's mad radio transmission of 7 x MAYDAYs before crash impact IMO points more towards some sort of cognitive failure (brain block) and less towards the pilot's lack of IFR proficiency. Also IMO, this apparent cognitive failure would no doubt have been exacerbated by the pilot's peripheral vision of a DFO wall of concrete looming up towards him, hence the panicked 7 x MAYDAY call. 



Via the UP, Lead Balloon related comment...  : https://www.pprune.org/pacific-general-a...st11114411

Lookleft

There you go LB, the Victorian Coroner has exercised his discretion:


https://www.abc.net.au/news/2021-09-...ring/100480126

---

Lead Balloon

 The insurance litigation will be the 'main game' with the Essendon tragedy. Very rich yanks involved.


The coronial will nonetheless be interesting, punctuated by the kinds of sensational headlines as are at the link in your post.  

Much MTF me thinks..P2 

[Cap'n Wannabe]

I am very curious as to whether Mr Quartermain was suffering a medical event during the takeoff. Medical events are not necessarily flick the switch and the lights go out - they can sneak up on you very gradually. So gradually that you don't notice. Or your girlfriend doesn't notice.
When you suffer an emergency in an aircraft, there are certain drill you follow, depending on the nature of the emergency, and when it occurs. If Mr Quatermain was suffering say a neurological episode, those drills could well have flown out the window.
IMO, it could explain the panicked Mayday calls..

[thorn bird]

We will probably never know exactly what events, either Physically or mechanically that precipitated this tragedy.

Australia alas does not have a truely independent accident investigator or, some would say a particularly competent one either. Given CASA dictates what conclusions the ATSB comes to in any investigation and given CASA manages its responsibilities more than anything else to absolve itself and its minister from any liability for anything, there is not much hope that anything will surface that is meaningful from the coroner. Be nice to know how many lawyers CASA is allocating to ensure the coroner comes to the "right" decision.

The industrial development degrading the safety of our airports by development sharks continues apace. At least at Bankstown, the massive structures already developed and them to follow, generating very dangerous wind shear when the wind doth blow, are large enough when there is an upset, to land on the roof, that is of course if the roof is strong enough. Now there's an idea, when all the available land is consumed for industrial development, ramps could be built and the roofs utilised as parking space for aircraft.( just Whimsy people!)

I see a foreign entity has acquired Jandakot airport for a huge amount of money. Much reporting on the profits they will make. To me, and I'm biased because I always thought airports were reserved for aviation use, it could be said this just illustrates how much the Australian public was defrauded by the "privatisation" of secondary airports, sold to development sharks for a pittance, giving them a monopoly to make billions.

Australia never learns the lessons of history, one day very soon we may come to regret the transfer of vital public infrastructure into private hands.

[Peetwo]

CASA and the Vic Coroner??

In the lead up to the pending Coroner's inquest report into the Essendon DFO accident I've started to do some probing into previous aviation accident dockets that the Vic Coroner has investigated - here's a couple where the Coroner puts questions to  CASA:

https://www.coronerscourt.vic.gov.au/sit...243605.pdf

---

https://www.coronerscourt.vic.gov.au/sit...458415.pdf

However the Vic Coroner link that caught my interest (& ire) was a CASA LEGAL AND REGULATORY AFFAIRS DIVISION reply to 2 Coroner's recommendations addressed to the regulator: link - https://www.coronerscourt.vic.gov.au/sit...0FLINN.pdf

14. CASA considers that training for inadvertent entry into IMC is more appropriate for
pilots rated only for VFR conditions. Without appropriate prior training and an aircraft
designed for IFR operations, such pilots are more likely to become spatially
disoriented or unable to safely operate the aircraft in IMC.

15. Therefore, while it does not propose to take any action in relation to this
recommendation at this stage, CASA is proposing a review of the competency
standards and the two-yearly review of proficiency rules (known as a flight review) for
private pilots in the next 18 months. A review of the basic instrument flying standards
and the related non-technical skills and human factors required of PPL holders will be
included in that review.

Hmmm...perhaps incoming?? 

MTF...P2 

[Peetwo]

A decade of obfuscating an open safety loop??

Via the embuggerance thread:

Also GlenB replies to Luce on the UP -  :

Luce

Dear Luce and others,

Please be assured that I value your comments.

I understand your sentiment. My matter is unique, in that it has no safety element to it all. There has never been any allegation of any safety concern with my operation at all. It was simply an allegation of a breach of the Civil Aviation Act that states “An Air Operator Certificate cannot be transferred. It is that fact that makes my matter unique, and I do run the risk of “muddying “my own case.

I have taken your advice on board, and it will be in my “considerations” going forward. Cheers.

As a final thought about the Bruce Rhoades matter. Drawing on 25 years’ experience in the flight training industry, I am fully satisfied that the young back packer in that incident would still be alive if:

The CASA Flight Operations Inspector (FOI) adopted this approach.

He/she was allocated 20 businesses by CASA, and committed to popping into each of those businesses once a month, for morning or afternoon tea, on a mutually convenient date.

They sat together for an hour and discussed matters with good intent. They built a relationship of confidence and then trust. A natural part of that conversation could have been as simple as “Run me through how you conduct adventure flights Bruce?” or “can I come along on one of your adventure flights Bruce”, or "how would you handle XXXXX Bruce?"

Any CASA concerns or questions could be resolved right back at that stage. The accident and fatality would most likely never have occurred.

Its hard to digest, but it really is that simple.

If the FOI turned up for morning or afternoon tea, and was told to bugger off, that would be a justifiable CASA concern.

The Operator that invites them in, as almost all would, with welcome arms is the Operator that will work collaboratively with CASA to improve safety and quality outcomes.

Its all well and good to have thousands of pages of documentation, laws, rules, advisories, regulatory philosophies, statements of expectation, exemptions, etc etc, but if the good intent and professional approach isn’t there, then it just won’t work. It really all starts with intent. Intent from the operator and intent from CASA.

The intent exists with the vast majority of operators, and CASA will know, because they will be invited in.

Sadly, and tragically, and most especially at the GA level, there would be less accidents if CASA choose to act with good intent. No amount of legislation can solve this very real problem that is so critical to flight safety in GA

That is what will improve safety outcomes. Good intent. CASA just doesn’t have the intent. Its not in the Organizational culture, and that stems from leadership..

In my own matter, and far closer to home. I operated only a few hundred meters from SOAR aviation. The truth is that industry, including other Government Departments raised safety concerns about that organization on multiple occasions, and repeatedly so over a protracted period. The Company had more accidents, incidents, than most, and even a fatality. That business went on right under CASAs nose and they knew about it. They ignored it. It wasn’t CASA that shut SOAR down. It was the students going to the Australian Skills and Qualifications Authority (ASQA), Its mind boggling.

ASQA was taking action against SOAR, while CASA was shutting me down. Its simply inexplicable at least.

By the way Luce, an industry colleague gave me a copy of “the art of war”, when this matter started. A very informative read, and after your post, I have located it for a re-read.

Cheers. Glen.

Also from the UP:

Checkboard

What's going on between about 0.37 to 0,45 (when '... something goes wrong' flashes up)? Doesn't exactly look like a reasonable thing to be doing with paying pax on board now, does it?

The operation was to land on the beach. A precautionary search and landing involves a low pass over the uncontrolled landing area to check for obstacles, like drift wood, and the suitability of the surface, which depends on the tide and weather. As part of the landing process, it is a permitted operation below 500 feet.

The prec search and landing is part of the PPL syllabus (or was when I was teaching 30 years ago), so every pilot should be aware of it.

---

Arm out the window

Hi Checkboard, fair enough to do a precautionary search, but why would you do it downwind at low level offset from the beach with very limited options in a power loss (as per what ended up happening?)

High recce followed by a pass along the strip into wind, offset enough to see but also able to get to it, would be how you would have taught it, or something along the lines of that, wouldn't it? It doesn't make any sense to be blasting along at low level with nowhere to go, which is why I don't think a strip assessment was the primary reason for having the aircraft in that position, although that's of course only my opinion.

The thing is, as Luce is I think getting at, Glen's arguments seem compelling and legitimate, and muddying the waters by drawing supposed parallels with others just because they too are in a stoush with CASA isn't likely to be particularly helpful to his cause. Everything I've seen of Glen's situation from what he's put up here and said on the record sounds fair dinkum. Some others making a lot of noise about being victimised do not appear to have the same credibility. Again, opinion only of course.

---

Squawk7700

Much quicker to do a downwind prec search, a quick u-bolt at the end to turn around, then land. Something you’d expect more from a crop duster.

Having much interaction with Bruce Rhoades (for about a year and a half before his passing), I found some of the above discourse insulting and ill-informed, for I know full well (with hand on heart) that Bruce was a well-intentioned operator that was not seeking to flagrantly break rules or to be in any way non-compliant with his obligations under the terms of his CASA issued AOC.

However the thread discourse did get me to going back over the ATSB Final report (AO-2017-005 - which IMO was cynically released a month after Bruce's passing). So in regards to the Arm out the window and Sqwawk7700 comments on the 'prec search' procedures for Wyndham Aviation I note the following from pg 38 of the FR: 

CASA advised that many flying training organisations have adopted the guidance provided by the Aviation Theory Centre, a publisher of commonly-used flight training manuals in Australia. This guidance included the following for carrying out a safe approach and landing at an unfamiliar field with engine power available:

• conduct a first inspection at 500 ft AGL circuit height, slightly to the right of the landing area (to check for obstacles on approach and departure and general condition of the landing surface)
• conduct a second inspection at 200 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (for a closer examination of the landing surface and other hazards)
• a third inspection at 50 ft, climb back to 500 ft before turning and conducting a 500 ft circuit (if required for a closer inspection of the landing surface)
• conduct the inspections with some flap extended (to provide a slower speed and other advantages, such as a smaller turn radius and better view from the cockpit due to a higher nose attitude).

     
Hmm...so was this accepted procedure for a prec search by FTO's throughout Australia disseminated by the CASA FOI oversighting Wyndham Aviation and then perhaps suggested that Wyndham Aviation should adopt as an SOP? This despite the fact that a 'prec search' procedure is in no way applicable to an operation that uses a beach landing area (ie a company defined ALA) on a regular basis and the definition of the procedure is a 'airborne inspection of a beach landing area' (quote from pg 39): 

The operator’s normal practice was to conduct an airborne inspection of the Middle Island ALA on the first fight of the day to the ALA and at other times when deemed by the pilot as necessary to inspect the beach landing surface. The chief pilot and pilot of the accident flight stated that between them they normally conducted one inspection each day that flights were conducted.

The chief pilot reported that, following a high tide, the beach conditions could change. The airborne inspection was therefore necessary in order to detect if there were any hazards such as ruts, pot holes, washaways, debris or areas of soft sand. He advised a good indicator of hard sand was the sand balls made by crabs.

The operator’s Operations Manual contained no guidance as to what height or configuration to use when conducting an airborne inspection, or how many passes to conduct. The manual required a pilot to look for the sand balls, and the chief pilot stated that in order to conduct an appropriate inspection (including looking for the sand balls) a pilot had to be at a low level.

       
Plus:

The pilot of the accident flight stated that such guidance applied to situations where a pilot was dealing with an unknown landing area, whereas their operations to Middle Island ALA involved a known landing area with conditions that could have changed.

The Operations Manual contained no guidance on what to do in the event of an engine failure at low level during an airborne inspection. The chief pilot stated that he had not considered the possibility of an engine failure during a low-level inspection. He also noted that pilots received training for engine failures at low level as well as precautionary search and landing during their basic training, and therefore he had not considered it necessary to require any further training or guidance in these areas.

Both the chief pilot and pilot of the accident flight noted that, at almost all stages of their flights to the beach ALAs, they had more than sufficient height to glide to and safely land on a beach in the event of an engine failure. They stated that the only exception, identified following the accident, was when doing an airborne inspection at the Middle Island ALA to the north (such as during the accident flight) (although see also Review of take-offs from Middle Island ALA and Operations over water and ditching procedures).

I could continue on down that rabbit hole but the point to note here is the part in bold: 

"..The Operations Manual contained no guidance on what to do in the event of an engine failure at low level during an airborne inspection..."

This brings me to page 43 of the FR under the heading "Airborne inspection procedures of another operator":

...The ATSB obtained the operations manual of another operator that routinely conducted passenger charter flights that involved landings at a beach ALA in small aeroplanes. The manual, last revised in 2015, included specific procedures that stated that beach landing area inspections had to be conducted no lower than 300 ft AGL.

The landing area inspections were generally conducted while flying downwind. However, the operations manual stated that inspections would typically be conducted ‘at an indicated airspeed no greater than 100 knots and it is preferable that a stage of flap is used for this procedure’.

This other operator’s beach ALA had significant areas of beach available at each end, and therefore a pilot could always land straight ahead in the event of an engine power loss during an inspection.

The other operator’s procedures also required that each pilot undergo a proficiency check every 90 days with a check pilot, and that such a check involved conducting a beach inspection...

Presumably the Ops Manual entries for the above operator were all CASA approved SOP additions. So why wasn't these 'safety risk' mitigation procedures generally disseminated (across industry) for operators conducting operations to approved (ALA) beach landing areas? 

This brings me to the safety issues section of the FR and in particular under the heading of 'Regulatory surveillance – scoping of surveillance events'- link: https://www.atsb.gov.au/publications/inv...005-si-08/

Safety issue description

The Civil Aviation Safety Authority’s procedures and guidance for scoping a surveillance event included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Which then brought me to the following disgusting, puerile response from CASA, one month before Bruce passed away..

Response by the Civil Aviation Safety Authority:

In August 2019, in response to the draft ATSB report, the Civil Aviation Safety Authority (CASA) stated:

CASA, as a regulator, has the ability to help ensure that an operator complies with aviation safety regulations and operations manual procedures through ongoing surveillance. Both CASA’s records and the draft [ATSB] report indicate that CASA had identified issues with the operator which were addressed (at least in terms of operations manual procedures).

However, the effectiveness of CASA’s system of regulatory surveillance and auditing in ensuring safety is based on the assumption that operators are genuinely interested in, and meaningfully committed to, compliance. What appears to have occurred in this case is that Wyndham Aviation had developed a culture of wilful, or at least habitual, non-compliance with both the safety regulations and the requirements of the Wyndham Aviation operations manual.

CASA has a robust entry control and oversight system which is continually under review and in this case additional or different oversight is unlikely to have significantly impacted the attitudes and behaviours of the operator.

- 

I then noted the ATSB response:

ATSB comment:

The ATSB notes that CASA has advised that it continually reviews its entry control and oversight system. However, the ATSB is concerned that CASA has not outlined any specific safety action to address this safety issue, nor has it undertaken any apparent safety action to effectively address a similar safety issue released in November 2017 (AO-2014-190-SI-14). Accordingly, the ATSB issues the following recommendation.

Curious I then went to the reference: AO-2014-190-SI-14

Where I discovered this 'safety issue' addressed to CASA was in reference to investigation report AO-2009-072 ie. the 1st PelAir Final Report??

Safety issue description

The Civil Aviation Safety Authority’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

According to the ATSB this safety issue was 'adequately addressed' - 

This was despite the ATSB final comment stating:

ATSB comment:

The ATSB notes the surveillance planning and scoping form provided by CASA to its inspectors is still the same as the form used from 2004–2009, and this form does not refer to the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.

Nevertheless, the ATSB acknowledges CASA’s surveillance processes have undergone significant evolution since 2009, and that it is continuing to review and develop its surveillance processes. It should also be noted that the ATSB will review CASA’s oversight processes since the introduction of the CSM in 2012 during the course of other investigations, including investigation AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion).

Hmm...to anyone with half a brain, does that sound like the 'safety issue' was 'adequately addressed'?

Again curious (as the reference rang a bell??) I went to this:  AI-2017-100 (Case study: implementation and oversight of an airline's safety management system during rapid expansion)

Overview of the investigation

As part of the occurrence investigation into the In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems.

The ATSB collected a significant amount of evidence and conducted an in‑depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore on 19 October 2017 a separate Safety Issues investigation was commenced to examine the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.

As part of its investigation, the ATSB:

interviewed current and former staff members of the operator, regulator and other associated bodies
examined reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
reviewed other investigations and references where similar themes have been explored.

Ahh...yes the ATSB/CASA cover-up/cock-up of the VARA accident: In-flight upset, inadvertent pitch disconnect, and continued operation with serious damage involving ATR 72 aircraft, VH-FVR, 47 km WSW of Sydney Airport, NSW on 20 February 2014

That saw a VARA ATR (post accident) fly around for a further 5 days and 13 sectors with a bent tail:


However. for an incident/accident that had the potential to result in the worst Australian air crash disaster (ie. a catastrophic airframe failure leading to multiple fatalities onboard, or worse if the aircraft was to crash into a highly populated suburb of Sydney) this was the outcome of the nearly 3 year 'systemic' investigation: 'Discontinued' -   

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Additionally, in the context that the investigation examined a time period associated with the early implementation of an SMS, it was also assessed that there was minimal safety learning that was relevant to current safety management practices. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation. The ATSB will also continue to examine safety management systems, and their oversight, in other systemic investigations.

Much...much MTF...P2 

[Peetwo]

Closing the loop on a regulatory tick-a-box regime?? -   

Courtesy Rotortech, via the Yaffa :

Pilots are the Problem: AHIA

29 June 2022



Australian Helicopter Industry Association (AHIA) president Ray Cronin has laid responsibility for the helicopter industry's flagging safety record squarely at the feet of pilots.

Already this year there have been eight helicopter crashes leading to nine deaths, including five people killed in one accident near Mount Disappointment in Victoria in March.

Speaking at the RotorTech conference last week, Cronin said the problem could be traced back to the airmanship of the pilots involved and a tendency to depart from established procedures.

"It really comes back to decision-making," he said. "If you look at all the individual accidents and think 'why did that one happen? Why did that one happen?', it really comes back to poor decision-making by the individual, not necessarily the company.

"So that's an area we really need to focus on, and it's been around since Noah built the Ark, so it's not new, but it's not getting through. And if you look at the age demographic of the accidents, it's not just the youth."

Cronin, winner of the 2018 Col Pay Award and owner of Kestrel Aviation, said that too many pilots were ignoring safety regulations and adopting their own practices, often leading to breaches of safety.

"History has shown that regulations are written in blood. Humans aren't good at being pro-active; we're very, very good at being reactive, so the guidance set that we provide to pilots seems to be accepted only as a need to pass an examination to get the licence and then go out and practice.

"So once you've got the licence you throw that over the shoulder and say 'now I'll use my own ruleset ... and I can do anything I want.' There's no boundaries; there's no triggers. There seems to be no vital, mental triggers that say 'no, I'm doing the wrong thing here.'"

Cronin pointed out that helicopters operate in a very dynamic environment, but if pilots adhered to the Pilots Operating Handbook, company Operations Manuals and other documented procedures, there is really no reason for a flight not to be completed safety.

He also noted that catastrophic component failure leading to an accident is "so low you can't really count it".

"The point I'm trying to get across here is that a helicopter is a very innocent device sitting on the ground all tied up," he said. "But if we put in the next element, the human factor, we now have a hazard or in the worst case, a lethal weapon.

"We need to get inside the heads of the people that operate the aircraft and make sure they respect guidelines."

Cronin singled out several common themes in helicopter crashes including flying after dark without qualifications or adequate instruments, fuel exhaustion, controlled flight into terrain and leaving helicopters running unattended.

According to Cronin, the safety record is starting to give the industry a black mark in the eyes of the public.

"We're effecting the public confidence in using helicopters, and this is in any sector: tourism, EMS, offshore," Cronin said. "People won't want to get on helicopters to go to work; they won't want to be rescued – they'll ask if there's another way to get off the cliff.

"It's a real problem and if we don't curb it, we start to restrict the industry, and the industry's already in enough trouble."

MTF...P2 

[Sandy Reith]

It’s hardly a revelation that pilots are in charge of their aircraft.

But does a ‘mea culpa’ attitude really progress our desire to make better?

Firstly we do need an atmosphere in General Aviation of responsibility rather than the fear of being caught. The present CASA induced environment is wrong and leads to the idea that it’s nearly impossible to fly within all the rules all the time. Some rules are contradictory, many are unworkable, impractical and often lead to excessive and unproductive costs.

Maybe once being in the habit of contempt for CASA and its rules then there’s an atmosphere of anything goes?

Certainly one thing stands out in our straight jacket of regulatory hell, there’s no room for innovation or change.
Ask Glen Buckley.

[Kharon]

Curiosity - a curse.

I read the 'Cronin' statement through a couple of times; more in idle curiously than deep interest - not having had much to do with helicopters and their operation. A couple of quotes made set me to wondering:-

"Australian Helicopter Industry Association (AHIA) president Ray Cronin has laid responsibility for the helicopter industry's flagging safety record squarely at the feet of pilots."

"He also noted that catastrophic component failure leading to an accident is "so low you can't really count it".

"Cronin singled out several common themes in helicopter crashes including flying after dark without qualifications or adequate instruments, fuel exhaustion, controlled flight into terrain and leaving helicopters running unattended."

A quick scamper through the ATSB data base left some questions which are probably worthy of some consideration; either Cronin is privy to information related to events which are not being reported and 'investigated: or, the ATSB ain't doing enough of it.

I only stepped back two years - July 04, 2020 and found investigation AO- 2020 -07. Within the following two year period there were 16 (sixteen) reports into helicopter events - none of which reflected the Cronin remarks as being 'part and parcel' of the event.

In 2020 - (A0-2020 prefix) we find reports - 07; 033;43; 64.

In 2021 (AO-2021 prefix) we find reports 007; 006; 018; 022; 035;

In  2022 (AO-2022 prefix) we find reports 006; 010; 09; 12; 16; 17; 030;

It is a mixed bag of 16 events - more or less reflecting world wide data (give or take) about what could be reasonably expected - component failure a statistical feature.

"We're effecting the public confidence in using helicopters, and this is in any sector: tourism, EMS, offshore," Cronin said. "People won't want to get on helicopters to go to work; they won't want to be rescued – they'll ask if there's another way to get off the cliff.

Seems to me a little unfair to blame all pilots for every event - considering the 'facts' ; the type of work being done and the accident report data. Still, they are the easiest target in the scapegoat game. I would have thought that blaming all on the pilots would be very detrimental to 'public confidence' - with every passenger wondering about the competence of the qualified, licensed driver of the bus to a fiery doom. Tempted to call 'bollocks' - alas, more research needed than I can be bothered to do...

Toot - unimpressed - toot.

[Wombat]

I suspect we are in the territory where “Learned Helplessness” may be a factor.

Learned helplessness: - “ Learned helplessness is a state that occurs after a person has experienced a stressful situation repeatedly. They come to believe that they are unable to control or change the situation, so they do not try — even when opportunities for change become available.”

The stressor is the mind blowingly complex regulatory system and the capricious, draconian and unfair enforcement system coupled with criminal liability as evidenced by review after review.

In other words, it is impossible to avoid breaking regulations whatever you try and do, so people give up trying to comply.

[Peetwo]

Coroner Inquest report: Nikita Jo Walker

Via Search 4 IP:

It is an old drum; but a good one.

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

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

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

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

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

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

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

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

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

Toot - toot...;

Via the other Aunty:

Coroner finds 2018 death of pilot Nikita Walker in Tasmania 'an accident', ATSB report slammed



The coroner's inquest into the death of a "talented and conscientious" pilot has failed to establish why her aircraft crashed into a mountain in remote southern Tasmania but has heavily criticised Australia's air safety investigator over its "worthless" report on the tragedy.

Nikita Walker, 30, was in control of a Pilatus Britten-Norman BN2A-20 Islander and had departed Cambridge, near Hobart on 8 December 2018 around 7:48am.

She was scheduled to arrive at Bathurst Harbour about 45 minutes later to pick up five passengers for the return flight.

Around 8:29am, the Australian Maritime Safety Authority was informed the emergency locator transmitter on the aircraft had activated and advised Tasmania Police.

In its report on the crash, the Australian Transport and Safety Bureau (ATSB) said when search and rescue aircraft arrived at the scene, they were "unable to visually identify the precise location" of the plane.

Key points:

• The coroner cleared Tasmanian airline Par Avion of any "systemic issues" in relation to pilot Nikita Walker's death
  
  
• He said Ms Walker was "attempting to avoid crashing by trying to find a break in the weather" before impact
  
  
• The coroner said the ATSB report "lacks much by way of reasoning, is largely speculative and … is of little forensic value"
  
  

The ATSB report noted the pilot of a rescue helicopter "reported observing cloud covering the eastern side of the Western Arthur Range, and described a wall of cloud with its base sitting on the bottom of the Western Portal" while at the scene.

In findings handed down on Thursday, coroner Simon Cooper said the evidence identified "no particular factor as especially causative or contributory" to Ms Walker's fatal crash.

"The evidence, viewed as a whole, does not point to any particular factor as especially causative or contributory to Ms Walker's fatal crash, Mr Cooper said."

"The aircraft was serviceable. Ms Walker was sufficiently experienced and appropriately qualified. She was well-rested and unaffected by either drugs or alcohol."

"Why she flew into the Western Portal is not something the evidence enables me to determine with any real certainty.

"I consider the clear evidence relating to her flight path immediately before the crash makes it obvious Ms Walker was attempting to avoid crashing by trying to find a break in the weather."

"It follows that I am satisfied that her death was due to misadventure, that is, an accident."



ATSB report into crash 'worthless'

Mr Cooper said: "In my view, in a general sense, the [ATSB] report lacks much by way of reasoning, is largely speculative and is, from my perspective at least, of little forensic value."

“One other obvious problem with the report … is that there is no indication of the author or author’s qualification to express the opinions and conclusions contained in it. In fact, there is even no indication as to the identity of the author or authors."

Mr Cooper said: "Perhaps most surprisingly, despite the fact that it was investigating an aircraft crash, the ATSB report does not appear to attempt to establish, at all, the reason for the crash."

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



Ms Walker had moved from Queensland to Tasmania to pursue her career as a commercial pilot with Tasmanian airline Par Avion in 2016.

She had been flying for two years at the time of her death in December 2018.

In his report, Mr Cooper noted her housemate said he and Ms Walker "had a cup of tea" the night before, with her going to bed "around 8:30 to 9pm" and getting up about 6:30am to make her way to work.

Mr Cooper cited Par Avion's submission that Ms Walker was "flying visually and under control" immediately before impact.

"In my view, the evidence enables a conclusion that until the very last moment of the flight, immediately before colliding with the Western Portal, Ms Walker remained in complete control of her aircraft," he found.

"What happened in the immediate moment before colliding … can only be speculation."

Mr Cooper said the evidence related to the crash also "does not reveal any systemic issue" in relation to the airline, Par Avion, or the weather forecasting by the Bureau of Meteorology.

Mr Cooper described Ms Walker as a "talented and conscientious pilot, popular with her colleagues and trusted by her employer".

He expressed his sincere condolences to all who knew and loved Ms Walker for their loss.

The ATSB and Par Avion have been contacted for comment.

(P2 - Cheers Wannabe well captured and copied mate... )

Plus via the Coroner report: https://auntypru.com/wp-content/uploads/...8.2022.pdf







Perhaps now might be a good time to reflect on how things have changed (NOT - ) since the publication of the PAIN_Net 2015 'Coronial Analysis' document: https://auntypru.com/wp-content/uploads/...alysis.pdf

---

Coronial Analysis. Fatal accidents.

Released – Senate Inquiry/RRAT_Folio. -1-

To whom it may concern.

One of the twenty five categories in a research project being undertaken by a small,
privately funded group of qualified, experienced aviation professionals focuses on
Coronial inquiries made in response to fatal accidents involving aircraft.

The purpose was, without bias, prejudice, fear, agenda or other motive to achieve a
clearly defined goal. The improvement of safety for the travelling public and the
people who work within the aviation industry.

The approach to the construct has been simple, and asked only two questions.

a) Was the accident preventable ?.
b) What steps have been taken to prevent repetition in similar circumstances ?.

Research was conducted over a wide area including:-

a) Extensive operational background analysis, private anecdotal and publicly
available data; and, considered expert opinion.

The intent was to present alternative or revised assessment of accidents where, in
the opinion of the group, the most probable and ranked contributing causes related
to the incidents were not clearly defined or presented for Coronial considerations.

It became apparent over some two hundred man hours of research into some thirty
investigations that 3 powerful elements were effectively preventing a satisfactory
conclusion to clearly defining the contributing causes and pro active prevention of a
similar repetition of the event.

We noted the following items:-

1) The frustration expressed by various Coroners, through transcripts, where
trying to establish a clear picture through the lack of deep technical knowledge
and sound advice.
2) The frustration expressed by the Australian Transport Safety Bureau (ATSB) in
almost every report published, where sound advice and research has been belittled
or waved aside as insubstantial.
3) The seemingly deeply entrenched culture of constant antagonism and
abrogation of responsibility existing between the Civil Aviation Safety Authority
(CASA) and the ATSB.

These issues appear to often place the Coroner in the invidious position of having to
make a choice between 2 'expert' opinions.

The following incident reports are from a wide range available for consideration;
they, we believe encompass the issues noted.

We believe that non of the promised legislation, against which many Coroners
based their recommendations, is available for practical use.

We believe none of the Coroners recommendations have been adopted to produce,
in any practical, meaningful way improved safety outcomes.

We believe that, in real terms, there has been no pro active approach to reduce
the self evident risks or casual factors related to the provided reports.

We firmly believe that all the presented incidents still have the potential to be
repeated.

The report editors.

---

MTF...P2