[Peetwo]

Proof of ATSB delays and ICAO Annex 13 non-compliance?? - 

To begin I refer to this recent ICAO response to a FAQ:

What are a State’s reporting obligations during and after an aircraft accident investigation?

Under Annex 13 to the Chicago Convention, States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

The State conducting the investigation of an accident or incident shall also make the Final Report publicly available as soon as possible and, if possible, within twelve months.

If the report cannot be made publicly available within twelve months, the State conducting the investigation shall make an interim statement publicly available on each anniversary of the occurrence – detailing the progress of the investigation and any safety issues identified.

For accidents or incidents involving an aircraft of a maximum mass over 5 700 kg, States in charge of an Annex 13 investigation must submit a copy of the accident investigation Final Report to ICAO.

However in Popinjay's bureaucratic Wonderland we (the Aussie 'WE') have apparently made a notified difference to ICAO Annex 13 Para 7.2...

Detail of Differences: Australia will comply with the standard for the more complex
accidents. However, for some less complex investigations Australia does not prepare a Preliminary Report.

Note that there is no mention in the "ND" about not complying with: "..submit a Preliminary Report to ICAO within thirty days of the date of the accident.." 

Referring to the aviation investigations pages, perhaps the above "ND" explains why Popinjay now has a formidable backlog of 'pending' AAIs that are mostly listed as 'Short (IE less complex) Investigations' that do not have a prelim report?? 

I can go back 8 pages and 2.5 years on the above link and still find a 'pending' investigation that doesn't have a preliminary report or (except for one) an interim report associated with it:

The list:

1. AO-2020-043 (Short)
2. AO-2020-059 (Defined)
3. AO-2020-060 (Short)
4. AO-2021-004 (Short)
5. AO-2021-022 (Short)
6. AO-2021-017 (Short with preliminary report issued - WTF??)
7. AO-2021-035 (Short)
8. AO-2020-059 (Note: This is a 'Defined' investigation and did have an update 2 months after the accident but none since)
9. AO-2020-060 (Short)
10. AO-2021-004 (Short)
11. AO-2021-018 (Systemic)
12. AO-2021-022 (Short)
13. AO-2021-032 (Short with a preliminary report attached and a safety advisory notice issued)
14. AO-2021-035 (Short)
15. AO-2021-044 (Short)
16. AO-2021-043 (Short)
17. AO-2021-048 (Systemic)
18. AO-2021-047 (Defined)
19. AO-2022-007 (Defined)
20. AO-2022-010 (Defined)
21. AO-2022-012 (Defined)
22. AO-2022-019 (Defined that bizarrely did issue an interim report 7 months after the incident)
23. AO-2022-025 (Short)
24. AO-2022-030 (Short)
25. AO-2022-031 (Short)
26. AO-2022-033 (Short)
27. AO-2022-032 (Short with a preliminary issued)
28. AO-2022-035 (Short)
29. AO-2022-036 (Short)
30. AO-2022-038 (Short)
31. AO-2022-039 (Short)
32. AO-2022-040 (Short)
33. AO-2022-042 (Short)
34. AO-2022-046 (Short)
35. AO-2022-049 (Short)
36. AO-2022-050 (Short)
37. AO-2022-053 (Short)
38. AO-2022-054 (Short)
39. AO-2022-052 (Occurrence Investigation)
40. AO-2022-055 (Short)
41. AO-2022-056 (Short)
42. AO-2022-058 (Short)
43. AO-2022-060 (Short)
44. AO-2022-061 (Short)
45. AO-2022-063 (Short)
46. AO-2022-062 (Short)
47. AO-2022-059 (Short)
48. AO-2022-064 (Short)
49. AO-2022-065 (Short)
50. AO-2022-066 (Occurrence Investigation)
51. AO-2022-067 (Defined)
52. AO-2022-068 (Occurrence Investigation)
53. AO-2023-002 (Short - Past 30 day limit for preliminary report)
54. AO-2023-004 (Short - Past 30 day limit for preliminary report)
55. AO-2023-005 (Short - Past 30 day limit for preliminary report)
56. AO-2023-007 (Occurrence Investigation - Past 30 day limit for preliminary report)
57. AO-2023-008 (Systemic - Past 30 day limit for preliminary report)
58. AO-2023-009 (Short - Past 30 day limit for preliminary report)

Hmm..I think I understand now why Popinjay was so keen to duck shove the Gympie midair fatal accident - UFB! Ironic that out of the myriad of outstanding investigations (highlighted above), that the Gympie midair has probably more hallmarks of a truly significant systemic investigation than all of the 'short investigations' (besides QF28) in the last 2.5 years...

I wonder if Popinjay has heard of the word 'discontinue'??

I say the proof in the pudding is when you consider that yesterday the ATSB released this load of bollocks:

Depressurisation incident highlights the importance of prioritising the use of oxygen when there is a risk of hypoxia, effective mitigations for known design limitations



Conflicting information due to a known design limitation, unclear guidance in the flight crew techniques manual, and distractions contributed to the flight crew of an Airbus A330 delaying the donning of their oxygen masks after receiving a cabin pressure altitude warning, an ATSB investigation report details.  

The Qantas-operated A330-202 aircraft was conducting a scheduled passenger service from Sydney to Perth on 4 February 2021 when about 2 hours into the flight while cruising at flight level 400 (about 40,000 ft), the pilots were presented with an excess cabin altitude alert, due to the cabin altitude exceeding 9,550 ft.

“This alert, on the aircraft’s Electronic Centralised Aircraft Monitor (ECAM) flight deck display, required the crew to don their oxygen masks and initiate an emergency descent to 10,000 feet,” said ATSB Director Stuart Macleod.

“Donning their oxygen masks immediately in response to the alert would have allowed the crew time to continue to trouble-shoot conflicting information while mitigating against any risk of being affected by hypoxia.”

Jet aircraft cabins are typically pressurised to a cabin altitude of less than 10,000ft, due to the dangers of hypoxia. The effects of hypoxia are most critical at altitudes above about 20,000 ft, but exposure to altitudes within the 11,000 ft to 20,000 ft range can lead to cognitive impairment.

In this incident, despite the crew being presented with the excess cabin altitude alert, the aircraft’s pressurisation system data display indicated that the pressurisation system was operating normally, leading the flight crew to doubt the validity of the alert.

“As a result, the flight crew sought additional information, including guidance from the Flight Crew Techniques Manual (FCTM),” Mr Macleod noted.

“This, and other distractions, delayed the crew in actioning the required procedural response of donning their oxygen masks and conducting an emergency descent to 10,000 ft.”

Mr Macleod noted there was no immediate risk of hypoxia for the passengers on board. If the cabin’s pressure altitude exceeded about 14,000 ft, detected by a pressure sensor separate to that used for cabin pressure control, individual masks for each passenger would have deployed.

The A330 is fitted with dual Cabin Pressure Controllers (CPCs) that automatically control the aircraft’s pressurisation, with one CPC controlling pressurisation, and the second serving as a backup.

During the incident flight, a fault occurred in the CPC controlling the aircraft’s pressurisation, resulting in the cabin slowly depressurising.

“This loss of pressure was detected by the standby CPC, which triggered the excess cabin altitude alert when the cabin altitude exceeded 9,550 ft,” Mr Macleod noted.

“However, a known design limitation meant that the controlling CPC was unable to detect a fault with its pressure sensor, resulting in the loss of cabin pressure control and the subsequent increase in cabin altitude. This limitation also resulted in the systems display continuing to present pressurisation data from the CPC in control, which directly conflicted with the alert.”

In response to that known limitation, Airbus required flight crew to action the excess cabin altitude alert irrespective of whether there was confirmatory data.

“However, when faced with conflicting information, and in line with operating philosophies, the crew sought evidence to verify the failure, delaying the donning of oxygen masks and commencing an emergency descent to 10,000 ft.”

Their response was further compounded by uncertainty on the procedural guidance in the FCTM.
About 7 minutes after the alert triggered, the flight crew donned their oxygen masks, and commenced a diversion to Adelaide with a precautionary descent to 10,000 ft, the report notes.

Shortly after the descent was initiated, the displayed pressurisation data indicated a sudden increase in the cabin altitude, to which the flight crew responded by immediately commencing an emergency descent.

The aircraft levelled at 10,000 ft and continued to Adelaide without further incident.

“Whenever there is a risk of hypoxia, the flight crew’s priority must be to immediately commence the use of oxygen,” Mr Macleod said.

Airbus had issued a service bulletin that would have corrected the design limitations and prevented the loss of cabin pressure control from the pressure sensor fault. However, this service bulletin had not been incorporated on the incident aircraft and there has been very limited uptake of the service bulletin across the global fleets of affected Airbus aircraft.

“The ATSB encourages Airbus A320, A330 and A340 series aircraft operators to pro-actively incorporate the Airbus service bulletins intended to prevent similar cabin depressurisations from Cabin Pressure Controller pressure sensor faults,” Mr Macleod said.

In addition, Airbus has advised the ATSB that it is evaluating the mitigations currently in place to address the cabin pressure control system design limitations. However, the ATSB has issued a formal safety recommendation to Airbus as its proposed safety action to address the design limitations and a timeline for their implementation have not yet been provided.

Mr Macleod also noted that the investigation highlights the importance of checklists, which are an aid to memory and help ensure that critical items necessary for the safe operation of the aircraft are not overlooked or forgotten.

While the specific Airbus requirement for responding to the ECAM alert was contained within a preamble to the flight crew operations manual abnormal procedure; it was not part of the ‘read and do’ procedural steps in response to the alert, and was reliant on memory recall.

“All essential components of a procedure must be included within that procedure’s checklist.”
Read the report: AO-2021-005 Cabin depressurisation involving Airbus A330, VH-EBK 235 NM (435 km) south-west of Adelaide, South Australia on 5 February 2021

Publication Date
21/03/2023

     
Hmm...so much for Hoody's 'Back on Track' program:

"...Concurrently, we have progressed a sub-program known as “Back on Track” which by design has allowed us to accelerate the completion of approx. 50 investigations that had overrun duration and effort targets..."

Ref: https://itsasafety.com/wp-content/upload...17-tpd.pdf

With all of the above in mind, why is it that the likes of Popinjay, Walsh and Pelham believe the ATSB has the corporate ability to take over the likes of OTSI and CITS when the ATSB executive management has been proven to be totally inept, a total clusterduck and can't even deal with it's own workload?? 

OTSI investigation: Safety and assurance systems for defect management (critical steering controls) in the Emerald Class Generation II Fleet - anticipated completion 1st quarter 2033??

MTF...P2 

[Sandy Reith]

A clear case of lack of Ministerial oversight, typical of a government’s administrative duty being palmed off to an independent statutory body. In this case the then Minister Albanese in 2009 pushed out the ATSB from his Department stating that it should not be subject to politics (Hansard). Such a simple minded excuse to rid himself of responsibility shows how our democratic institutions can be overturned or disregarded with almost zero comment. Such is the paucity of intellect on display here, a naïveté that beggars description.
Take Mr. Albanese’s argument a little further, all the various arms of government to be independent with no sanction, ballot box or otherwise, for poor performance and let’s see where that takes us.

[Gentle]

A clear case of lack of Ministerial oversight, typical of a government’s administrative duty being palmed off to an independent statutory body. In this case the then Minister Albanese in 2009 pushed out the ATSB from his Department stating that it should not be subject to politics (Hansard). Such a simple minded excuse to rid himself of responsibility shows how our democratic institutions can be overturned or disregarded with almost zero comment. Such is the paucity of intellect on display here, a naïveté that beggars description.
Take Mr. Albanese’s argument a little further, all the various arms of government to be independent with no sanction, ballot box or otherwise, for poor performance and let’s see where that takes us.

I know the Royal Commission has not published its final report but Sandy tell me how Robodebt happened…

I almost agree with everything you say but putting back AsA, CASA and ATSB directly in the department will not solve the problem.  It could make things worse… especially under either of the major parties….

Hmmmm how does the UK do it? I AM NOT BELITTLING YOUR CONCERNS! My considerable experience in one of the three and closely observing the other two would probably indicate your concerns are understated.

After watching the Utopia episode on Defence whilst concurrently watching in another video window Paul Keating at the NPC, well the best comedy ever, ROTFALMAO! Satire imitating life or life imitating satire. Perhaps both at he same time?

Canberra politicians and associated bureaucrats are a far greater Clear and Present Danger than an IndoPacific Major Regional player grabbing the money under my bed where I had placed it after SVB failed…

Sigh on both counts…..

[Kharon]

Gentle - Hmmmm how does the UK do it? I AM NOT BELITTLING YOUR CONCERNS! My considerable experience in one of the three and closely observing the other two would probably indicate your concerns are understated.  (Amen)...Well said Sir....

You can't roller skate in a buffalo heard.
You cant knock in a 4” nail with a banana.
You can't get a spark plug out with a teaspoon.
You cannot, not under any circumstance, allow the lunatics to run the asylum.

To get anything done, properly and finished tidy, you must have the right tools. Those tools must be in the hands of someone who knows how to use 'em. Gifted amateurs need not apply.

Every 'agency' associated with the aviation industry suffers from the same clearly defined malaise. They are all adequately funded (very); they all have the ability to request additional funds. They are all, essentially, independent of political interference and far removed from being accountable to the minister du jour, Senate estimates, ATO audit, ICAO, the rule of law, or even parliamentary 'debate' of any rule change, or even the industry they are alleged to serve.

It has been many a long year since there was a minister who took an interest; even longer since we had a minister who even vaguely understood what was needed to ensure the future well being of an industry. Look around you today at whats left; or check out the fantastic fees paid by our air farce to operate from Canberra. The results of political disassociation from responsibility writ large.

But, you can't blame the Pollies, not really, not for everything.  Say, for sake of discussion, there was a minister who realised aviation was in a diabolical mess. The heads of those agencies are hauled into the office – tea, biscuits and 'please explain' time. “I want this sorted out” bellows the minister. “Fine, but how do you suggest we do that minister”? say the three alleged experts. You see the problem; its like me telling NASA to fix the Hubble telescope.

The crux of the matter (IMO) resides with the 'head' of the agency portfolio. For example, like the DAS of the CASA circus (one of three examples available). Compare that to the likes of Jim Betts. Betts may not be 'perfect' but he at least has a grasp and a notion of 'how to'. Spence has no idea as to whether she is punched, bored or countersunk. Yet the expertise and advice is freely available, alongside some fairly hefty 'political' assistance – to make the changes needed and demanded by industry; all there, just need the will to pick up the tools and use them; once freed from the tentacles of the monster which holds her fast. Easy fix, here's the letter we all want to see:-

Dear Industry Participant. (Nutshell version)...

“This to advise that in January 2026 we will be adopting the ICAO compliant FAA rule set; the FAR (or Kiwi version – not fussy). The template for revised Operations Manuals and compliance is available from the CASA website. ”Etc......

From that moment it is simply a matter of logistics; seminars in capital cities with an expert panel from the USA; some heavy duty homework for whoever gets lumbered with drafting the manuals; couple of years hard work, overseas assistance and expertise; and – 'just like that' watch Australian aviation show how capable it truly is.

With the right leadership all three agencies could be doing a much better job. Alas; what we now have, masquerading as 'expert' could not, with a candle to assist, find a cat in a cat house. Want to knock a nail in – try a hammer.

Toot – toot.

[Peetwo]

Rationale for ATSB delays?? 

Via the Oz (thank you Wannabe...  ):

‘Complex and dynamic’: Outback Wrangler crash report delayed



The Australian Transport Safety Bureau has delayed the release of its final report into the fatal Northern Territory chopper crash that killed Outback Wrangler cast member Chris “Willow” Wilson as multiple investigations into the incident and its aftermath continue.

Almost 14 months after Wilson was killed during a crocodile-egg collecting mission in a remote part of West Arnhem Land, the ATSB has updated the anticipated completion date of its final report from June to September this year.

The national transport safety investigator told The Australian on Thursday that while it had originally planned to release its findings by the end of 2022, its deadline had been repeatedly pushed back as the investigation had been broadened and upgraded.

“During a recent regular management scoping review, it was determined that due to the complex nature of this investigation, the release of the final report is now anticipated for the third quarter of this year,” an ATSB spokesperson said. “By their nature ATSB investigations are complex and dynamic and it is common for investigation timeframes and scopes to be adjusted as evidence is analysed and further evidence is obtained as the investigation team develops its findings.”

The destroyed R44 Raven II, registered VH-IDW, was owned and operated by Netflix star Matt Wright’s company Helibrook which remains under investigation by the Civil Aviation Safety Authority.

The ATSB updated the investigation page on its website on the same day it released a damning report into a Broome helicopter crash that killed Wright’s friend and former business partner Troy Thomas and a 12-year-old girl.



Thomas, who was the pilot, and Amber Millar died when the 40-year-old’s R44 Raven I helicopter crashed just after takeoff from an industrial area north of Broome airport in July 2020. The report released last Wednesday detailed how the accident was caused by the tail rotor tearing free during a high-powered vertical takeoff.

The ATSB found that tourism stalwart Thomas was not legally authorised to fly the chopper, had previously demonstrated acts of noncompliance with multiple aviation safety regulations, and operated the crashed aircraft in a manner that increased the risk of damage on multiple occasions.

“There was also evidence that the pilot was willing to take, and expose others to, elevated risk,” the report said.

Australian Securities and Investments Commission records show Thomas and Wright were business partners from 2015 to 2018. They started Top End tourism venture Outback Floatplane Adventures together before Wright sold his share to Thomas in 2018 to prioritise his burgeoning television career as National Geographic’s Outback Wrangler.

Meanwhile, multiple agencies are all still scrutinising what happened before, during and after the crash that killed Wilson on February 28 last year.



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

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

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

In November NT Police charged Wright with attempting to pervert the course of justice, destroying evidence, fabricating evidence, unlawfully entering a building, making a false declaration and interfering with witnesses. All three will return to the Darwin Local Court on May 31.

MTF...P2 

[Peetwo]

Number 13. from the list completed - 

Via Proof of ATSB delays and ICAO Annex 13 non-compliance??

13. AO-2021-032 (Short with a preliminary report attached and a safety advisory notice issued)

Via the Popinjay home page we get the now familiar media blurb, courtesy of this week's Director Transport Safety Kerri Hughes:

Acroduster in-flight break-up highlights importance of additional inspections



Key points

• Amateur-built Acroduster aircraft broke up in-flight when the left and right eye bolts and left roll brace connecting its upper wing failed due to fatigue cracking;
  
• A safety advisory has been issued by the ATSB, as well as the aircraft design owner, the US Federal Aviation Administration, and the Experimental Aircraft Association;
  
• [size=1]ATSB urges operators and maintainers of amateur-built aircraft to consider additional detailed inspections of parts of aircraft that are critical to safe flight.
  

The in-flight break-up of an amateur (kit) built Acroduster aircraft reinforces to operators and maintainers of these aircraft the importance of conducting additional detailed inspections of areas that are critical for flight.

On 18 August 2021, an amateur-built Stolp Acroduster II SA-750 biplane broke-up during a flight from Caboolture airfield, north of Brisbane. The pilot, who was the sole occupant, was fatally injured.

As noted in its preliminary report, the Australian Transport Safety Bureau’s technical examination determined two eye bolts, and the left roll brace, used to secure the aircraft’s upper wings, had failed due to fatigue cracking, triggering the break-up sequence.

Coinciding with the release of its preliminary report, the ATSB issued a Safety Advisory Notice (SAN) to owners and maintainers of Stolp Acroduster SA-700-750 aircraft, notifying them of the fatigue cracking issue.

“In this accident, the fatigue cracks formed in an area of the eye bolts that were obscured by the securing nuts and threads of the eye bolts,” ATSB Director Transport Safety Kerri Hughes said.

“This meant the cracks would not have likely been readily identifiable during standard maintenance inspections, without disassembling the attachment points.

“Owners and maintainers of experimental amateur-built aircraft should consider conducting additional detailed inspections that exceed the minimum standards, in areas of the aircraft that are critical to the safety of flight.”

The initial finding of fatigue cracking on the aircraft’s eye bolts was immediately shared, in August 2021, with the Civil Aviation Safety Authority, as well as the National Transportation Safety Board and Federal Aviation Administration in the United States (as the aircraft’s state of design), and the US-based Experimental Aircraft Association.

The aircraft design owner, Aircraft Spruce, was also notified.

The Experimental Aircraft Association subsequently released a notice on its website informing members of the accident, and a link to the ATSB’s preliminary report and SAN.

The Federal Aviation Administration issued a notice to more than 280,000 web subscribers informing them of the wing attachment point fatigue cracks, and also provided a link to the ATSB’s material.

Additionally, Aircraft Spruce issued a safety advisory notice to every purchaser of Starduster and Acroduster design plans since 2003.

“The ATSB welcomes these safety actions by authorities and the manufacturer in response to this accident,” Ms Hughes concluded.

Read the report: AO-2021-032: In-flight break-up, Stolp Acroduster II SA-750, VH-YEL, 16 km north-east of Caboolture airfield, Queensland, on 18 August 2021

Publication Date
28/04/2023

Not sure why the general statement..

“Owners and maintainers of experimental amateur-built aircraft should consider conducting additional detailed inspections that exceed the minimum standards, in areas of the aircraft that are critical to the safety of flight.”

...could not have been issued when the preliminary report (47 days non-compliant with ICAO Annex 13) and the SAN were both published on 3 November 2021? And why it took a further 17 months and 25 days to complete a 'Short Investigation - ???' when it appears that the DIPs had all been informed and that there has been very little additional information or additional findings added since the prelim report was published?

"..The initial finding of fatigue cracking on the aircraft’s eye bolts was immediately shared, in August 2021, with the Civil Aviation Safety Authority, as well as the National Transportation Safety Board and Federal Aviation Administration in the United States (as the aircraft’s state of design), and the US-based Experimental Aircraft Association.

The aircraft design owner, Aircraft Spruce, was also notified.."   

The SAN:

Safety advisory notice

AO-2021-032-SAN-01:

The Australian Transport Safety Bureau advises all owners, operators and maintainers of Stolp Acroduster SA‑700/750 aircraft to consider the safety implications of the initial findings of this investigation regarding the fatigue cracking on forward cabane strut upper wing attachment eye bolts, and take action where considered appropriate to ensure that their aircraft remain airworthy.

Read more about this ATSB investigation at: AO-2021-032 link to preliminary report

Finally, how does this investigation meet the ATSB definition of a 'Short (desktop) Investigation'??

Short investigations

Short investigations provide a summary and analysis of commonly occurring transport safety accidents and incidents. Investigation activity includes sourcing imagery and documentation of any transport vehicle damage and/or accident site, conducting interviews with involved parties, and the collection of documents such as procedures and internal investigations by manufacturers and operators.

Short investigation reports include a description of the sequence of events, limited contextual factual information, a short analysis, and findings. Findings include safety factors (the events and conditions that increased the risk of incident or accident happening) but only examine the actions and conditions directly relating to the occurrence and any proactive safety actions taken.

MTF...P2 

[Peetwo]

Number 18. from the list completed??

Head of ATSB YBBN office, Dr Walker presents: https://www.atsb.gov.au/media/news-items...d-practice

737 freighter failed to pressurise due to normalised but unauthorised practice



A 737 freighter aircraft failed to pressurise after a cargo depressurisation switch was left on during preflight preparations, an Australian Transport Safety Bureau report details.

The Boeing 737-36E SF (an aircraft built as a passenger airliner but subsequently converted to a freighter) was being operated by Airwork on a flight from Darwin to Brisbane on 4 November 2021.

After take-off, the flight crew observed the aircraft did not pressurise as expected. After stopping the climb at 11,000 ft, the flight crew began to descend to 10,000 ft, during which time a cabin altitude warning alert occurred.

Once at 10,000 ft, the crew completed required checklist actions, but were unable to establish control of the pressurisation. Subsequently the equipment cooling fan failed, the electronic flight information system reverted to a monochrome display output, and the weather radar failed.

The crew made the decision to return to Darwin for an uneventful landing.

“On arrival it was identified that the guarded cargo/depress switch was on,” ATSB’s Dr Michael Walker said.

“This switch was normally only used in the event of a main cargo deck smoke event, when it will depressurise the aircraft to assist smoke removal.”

The ATSB found the switch had been turned on by a maintenance engineer during pre-flight preparation, in an attempt to cool the flight deck. The engineer omitted to turn the switch off prior to completing their duties, and this was not identified by the flight crew.

“Using the switch in this manner was not authorised, but it had become normalised by the operator’s staff in Darwin, where there was no ground support equipment to provide external cooling,” Dr Walker said.

“Even though this practice had become normalised, there were insufficient risk controls in place to ensure that the aircraft would be returned to the correct configuration prior to departure.”

Additionally, the ATSB investigation found a pre-flight check of the switch was not incorporated into the operator’s flight crew operating manual, despite the aircraft’s cargo conversion operations manual stipulating it as a requirement.

Since the incident, the operator issued communications to its staff to immediately cease the unauthorised practice, and remind staff to only operate equipment in accordance with approved documentation.

Additionally, the operator commenced a review of operational documentation and completed incorporating the requirements of the operations manual supplement.

“This incident highlights the risks associated with undertaking unauthorised practices and using equipment in a manner other than for its intended purpose,” Dr Walker said.

“Without formal assessment of its efficacy or its potential for unintended consequences, combined with no documentation of training, there is no assurance that an unauthorised practice would be carried out consistently or safely.”

Read the final report: Cabin pressurisation issue involving Boeing B737-36E SF, ZK-FXK, near Darwin Airport, Northern Territory, on 4 November 2021

Publication Date
16/05/2023

On the face of it this was a relatively straight forward investigation, which besides the crew etc interviews, probably relied on a copy and paste review of the internal operator SMS investigation.

Although this investigation was listed as 'Defined' it did not have an associated preliminary report or an interim report on the anniversary date of the incident (IE Non-compliant with ICAO Annex 13). The investigation took 18 months and thirteen days.

The ATSB Aviation accident investigations webpage no longer brings an update to an investigation to the top of the page. Nor do the individual investigation webpages now have a date for the latest update or a share link.

So if it hadn't been for the Dr Walker media blurb you would have to troll back through 5 pages of ATSB AAIs to find out that the AO-2021-047 investigation had been completed to a final report. 

While on page 5 of the ATSB AAI webpages I discovered that recently (15/03/2023) there had been a discontinued investigation: 

Overview of the investigation

On 30 November 2021, a Boeing 777-300ER aircraft, registration A7-BED, was being operated by Qatar Airways on a scheduled passenger flight from Auckland, New Zealand, to Brisbane, Queensland. During the landing at Brisbane Airport, the aircraft veered off the runway.

The flight crew were conducting an instrument approach to runway 01R at night and the captain was the pilot flying. During the approach, the aircraft encountered heavy rain and turbulence. The crew reported that, at about 300 ft above the runway level and still in rain, they established and maintained clear visual reference to the runway lighting and surrounds, including the runway centreline and edge lights.

The crew stated that, passing about 200 ft, the first officer announced the aircraft was drifting right of the runway centreline. The captain corrected the deviation. As the aircraft was about to touchdown, under the influence of a variable and gusting crosswind, the aircraft drifted right again and the captain was unable to correct the drift before touchdown.

The aircraft landed to the right of the runway centreline and drifting to the right. Shortly after touchdown, the right main landing gear contacted and destroyed 4 runway edge lights positioned on the sealed runway strip, before the aircraft returned towards the runway centreline.

After the landing was completed and the aircraft had exited the runway, aircraft systems alerted the flight crew of low pressure in one on the right main landing gear tyres. The flight crew stopped the aircraft on the taxiway and requested an external inspection of the aircraft. Damage to 4 right main landing gear tyres was observed, and the aircraft was towed to the international terminal. There were no injuries to passengers or crew.

The ATSB received an initial occurrence report on 1 December 2021 and commenced an investigation on the same date.

As part of the investigation, the ATSB interviewed the flight crew and reviewed:

• data from the aircraft's flight data recorder and quick access recorder
  
• weather information
  
• recorded air traffic control audio and surveillance data
  
• information provided by the aircraft operator, including flight crew rosters and the fatigue risk management system.
  

[*]

The investigation identified the following:

• runway 01R is 45-m wide with a grooved surface and runway centreline lighting and runway edge lighting, and there were no problems noted with the runway lighting
  
• there were no notable faults with aircraft systems
  
• there were no notable concerns regarding the flight crew’s decision-making
  
• the flight crew likely maintained sight of the runway centreline and edge lights throughout the landing, and were able to detect the aircraft’s drift before touchdown
  
• there was a substantial lateral wind gust that changed direction and intensity when the aircraft was below 100 ft above ground level
  
• the captain reported feeling between ‘a little tired’ and ‘moderately tired’ after having less than normal sleep quantity and quality in the 2 nights before the flight
  
• the captain was probably experiencing a level of fatigue known to adversely influence performance due to limited sleep obtained in the previous 48 hours
  
• the flight crew’s flight and duty times and rest periods met the operator’s fatigue risk management requirements for at least the preceding 28 days and they had significant rest opportunity prior to a flight from Brisbane to Auckland on 29 November and the occurrence flight from Auckland to Brisbane on 30 November.
  

Reasons for the discontinuation

The ATSB strives to use its limited resources for maximum safety benefit, and considers that in this case it was unlikely that further investigation would identify any systemic safety issues or important safety lessons from this specific occurrence.

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.

[*]
Next from Popinjay HQ, courtesy of this week's DTS Stewie McLeod :

Parking brake likely not fully released prior to rejected take-off



Key points

• Parking brake likely wasn’t fully released prior to taxiing for departure.
  
• Residual pressure in the braking system led to heat build-up and further application of the brakes.
  
• The flight crew’s swift decision to reject the take-off demonstrated their effective monitoring of the aircraft’s performance.
  

The flight crew of a Saab 340 rejected the take-off after experiencing handling and acceleration issues likely due to the parking brake not being fully released, an ATSB investigation details.

The Pel-Air operated Saab 340B, with 2 pilots, a cabin attendant and 25 passengers on board, was departing Flinders Island for Wynyard, Tasmania, as part of a multi-flight charter tour on 4 November last year.

As it accelerated, the aircraft veered to the left of the runway centreline and the crew detected a decrease in acceleration before rejecting the take-off.

Afterwards, the pilots observed significant tyre marks on the runway, a flat spotted tyre, and that all main landing gear tyres were flat.

“The ATSB investigation found that the parking brake handle had likely not been completely seated in the panel when released by the pilot, resulting in residual pressure remaining in the brake system,” ATSB Director Transport Safety Stuart Macleod said.

During the taxi to the runway, the residual pressure provided a partial application of the brakes, which allowed heat to generate within the brake system, resulting in further increased pressure and a continual increase in brake application.

“As the aircraft accelerated for take-off, this heat generation increased significantly, resulting in further application of the brakes.”

Since the occurrence, the operator has taken a number of safety actions to prevent a reoccurrence, including disseminating a Notice to Aircrew to its pilots with detailed information of the operation of the parking brake.

“This occurrence demonstrates the importance of completing routine tasks in accordance with manufacturer’s instructions,” Mr Macleod said.

“The outcome of this event, no passenger injuries and minimal aircraft damage, was a result of the flight crew’s effective monitoring of the aircraft’s performance and prompt action to reject the take-off when the expected performance was not achieved.”

Read the final report: Rejected take-off involving SAAB 340, VH-ZRC, Flinders Island Airport, Tasmania, 4 November 2022

Publication Date 17/05/2023

MTF...P2 

[Peetwo]

No.29 from list completed; plus the Oz reports on AO-2022-054!! - 

From this week's DTS Stewie Macleod...

Tail rotor driveshaft failure demonstrates how unusual sounds and responses can be an indication of an imminent system failure



Brief, loud grinding noises precipitated the failure of a Bell 505 helicopter’s tail rotor driveshaft, an Australian Transport Safety Bureau report details.

On 15 July 2022, the Bell 505 was being used for a scenic flight from Cairns, Queensland, with a pilot and two passengers on board.

About 30 minutes into the flight, near Double Island, the pilot heard two brief, loud grinding noises, and elected to return to Cairns Airport.

Over the airfield, the grinding noise returned, and after 10-12 seconds, while approximately 10 ft off the ground, the pilot heard 2 loud bangs.

“In response, the pilot moved the throttle to idle, which stopped the yaw,” ATSB Director Transport Safety Stuart Macleod explained.

A run-on landing was performed on the grass short of the assigned helipad, and a subsequent inspection of the helicopter revealed the tail rotor driveshaft had failed.

“The ATSB determined that during landing, a combination of heat and torque due to a seized forward fan shaft bearing resulted in failure of the fan shaft just aft of that bearing,” Mr Macleod said.

Due to the amount of damage on the failed bearing, the ATSB was not able to identify the reason for the seizure, and the manufacturer, Bell Textron, advised the ATSB that it was not aware of any previous instances of bearing failure in 505 fan shaft bearings.

“Unusual sounds and responses from an aircraft can be an indication of an imminent system failure,” Mr Macleod continued.

“In this instance, the pilot’s decision to return to Cairns was probably influenced by the initial short duration of the unusual noises and overwater operation. While a safe landing on an airfield resulted, the occurrence also illustrates how quickly failures can occur.”

Mr Macleod noted pilot’s decision to adopt a shallow approach, and to reduce throttle immediately following the shaft failure, both assisted in controlling the helicopter following the uncommanded yaw, and allowed for a safe landing.

“This incident does highlight that pilots experiencing any unusual vibration or noise should land as soon as possible and have the aircraft inspected prior to further flight,” he said.

“If an immediate landing is not possible then pilot should be prepared to conduct an emergency landing or ditching if the situation deteriorates.”

Read the report: Tail rotor driveshaft failure involving Bell Textron 505, VH-VTB, Cairns Airport, Queensland on 15 July 2022[/size]

Publication Date
19/05/2023

This investigation was completed in another record completion time for the ATSB IE 10 months and 14 days. However it was still non-compliant with ICAO Annex 13 as there was no prelim report.

Comment from a SME:

"..Mmmm, out in good time only because they can’t determine what caused the shaft failure. I'm sure Bell weren’t to interested in sharing their dirt! Instead we get the gold advise to land if you hear banging noises. Duh!.."

As a point of comparison, for what is a NTSB version of a 'Short (desktop) Investigation', the following prelim report, with virtually zero media fanfare, was released yesterday:

---

---

 

Note that short factual prelim report took 2 weeks to produce. Will monitor the progress of this investigation...

Next, I note that the Oz has reported on the PelAir Flinders Island RTO Final Report...

Pel-Air pilots reschooled on aircraft parking brake after aborted takeoff

A six-month investigation by the Australian Transport Safety Bureau has found a charter flight to Tasmania was unable to takeoff because the pilots had not released the parking brake.

The Pel-Air operated Saab 340 had two pilots, a cabin attendant and 25 passengers on board, when the takeoff from Flinders Island was rejected because the plane was veering to the left and not accelerating sufficiently.

The Flinders Island airport operations officer reported seeing smoke coming from the aircraft’s wheels and radioed the flight crew to tell them.

“The first officer also recalled the aircraft felt like it was braking by itself, and that pressure was felt in the brake pedals under their feet,” said the ATSB’s final report.

The Saab 340 reached a speed of 96kts, or 177km an hour, before the takeoff was rejected more than a kilometre along the runway.



When the aircraft returned to the gate, the pilots noticed all four main landing gear tyres were deflated and significant tyre marks on the runway from the 300m mark to 1150m.

ATSB director of transport safety Stuart Mcleod said their investigation found the parking brake handle had not been fully released, resulting in residual pressure remaining in the brake system.

“As the aircraft accelerated for takeoff, this heat generation increased significantly, resulting in further application of the brakes,” said Mr Mcleod.

Since the incident on November 4, 2022, Pel-Air had taken a number of safety actions to prevent a reoccurrence, the ATSB noted.

-     

While on the subject of PelAir and the ATSB, I note that the 10th anniversary of the tabling of the infamous Senate PelAir report will occur on the same day that RRAT Budget Estimates should be reviewing the recent inept, shambolic performance of Popinjay and the ATSB -  : Budget Estimates: Popinjay & AMSA dodge Senate Estimates - WTD??   

Reflect on this speech by Senator Fawcett not long after the tabling of the Senate AAI report:

 

A decade down and what's changed? - I would argue that the state of aviation safety administration and investigation is WAY WORSE!! 

MTF...P2 

[Peetwo]

No.19 completed with Popinjay to the rescue - yet AGAIN??  

Bored and maybe miffed by not having to appear at Estimates, Popinjay took up the role as this week's talking head Director Transport Safety with comments on defined investigation AO-2022-007:

King Air lands off runway surface during visual approach to Lord Howe Island during a rain shower



A King Air aircraft with a pilot and six passengers on board touched down on the grass strip to the left of the runway at Lord Howe Island after conducting an approach and landing during a heavy rain shower, an ATSB investigation report details.

The aircraft, being operated by Eastern Air Link, was conducting a scheduled passenger flight from Port Macquarie to Lord Howe Island on the morning of 18 February 2022. Approaching Lord Howe at about 0800, the pilot commenced a DME (distance measuring equipment) instrument arrival procedure conducted under instrument flight rules.

Early in the DME approach the pilot established visual meteorological conditions and transitioned to a visual approach. The pilot then descended the aircraft visually below cloud while over the water to an altitude below 1,000 ft, while also positioning for a straight-in approach to runway 10. During the approach, the aircraft entered an area of reduced visibility in rain and then touched down to the left of the runway.

“At the time of the aircraft's final approach and landing, the Lord Howe Island aerodrome was experiencing a heavy rain shower with limited visibility, conditions that were marginal for visual flight,” said ATSB Chief Commissioner Angus Mitchell.

“While the pilot commenced a visual approach to the runway with the required visual cues, it was highly unlikely that the required visual contact with the runway was retained throughout the approach.”

The ATSB investigation found that, with the loss of visual cues, the pilot did not commence a go around, which was contrary to the missed approach requirements, and instead continued towards the runway. This resulted in an increasing displacement from the runway centreline.

“Late in the approach with the aircraft close to the runway but with a significant displacement from the runway centreline, visual contact with the runway was reacquired,” Mr Mitchell said.

“Considerable manoeuvring with significant heading changes were required to realign the aircraft with the runway, resulting in an unstable approach, and, ultimately, the aircraft touching down off and to the left of the runway, on the runway strip.”

The pilot was aware that the aircraft had touched down to the side of the runway, but at the time thought that only the left main tyre was displaced at or around the edge of the runway. They elected to therefore continue the landing, manoeuvring the aircraft onto the runway and completing the landing roll without further incident.

A postflight inspection of the aircraft did not identify any damage, however an inspection of the runway by the aerodrome operator identified ground marks from an aircraft’s tyres along the left section of the runway strip, and a broken runway edge light on the left side of the runway, about 1,000 ft (300 m) from the runway threshold.

The ground markings indicated that the aircraft had touched down on the runway strip, with the closest main landing gear to the sealed runway surface about 2 m from the edge, and that the aircraft had quickly regained the runway shortly after touchdown.

In addition, the investigation also identified several flights conducted by the operator that followed a similar approach profile as that used by the occurrence flight, which were also conducted in marginal weather conditions for visual approach operations.

This practice significantly increased the risk of reduced obstacle clearance assurance for both an approach and a potential missed approach. 

“Adherence to operational procedures ensures consistency of pilot action and aircraft operation during the approach and landing phases of flight. This, along with careful monitoring of aircraft and approach parameters, ensures approaches are conducted safely,” Mr Mitchell said.

The ATSB has issued a safety recommendation to the operator that it provides guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.

“Operators should encourage the use of the most appropriate and safe approach available,” Mr Mitchell said.

“When conditions are marginal, the use of an instrument approach that provides obstacle clearance assurance minimises the risks resultant from any unforeseen deterioration in conditions,” he continued.

“These approach types provide a protected flight path for any missed approach and have been shown to be significantly safer than a visual approach when weather conditions are marginal."

Read the report: Touchdown off the runway surface involving Raytheon B200, VH-MVP, at Lord Howe Island Airport, NSW, on 18 February 2022 | ATSB

Publication Date
24/05/2023

Got to wonder why Popinjay insists on making these media statements when it is a very profile incident? Why not let the report speak for itself? I also wonder what the annual cost would be for producing such word weasel waffle? Surely those resources would be better put to completing investigations in a more timely manner and in compliance with ICAO Annex 13? 

The investigation took an acceptable 15 months and 7 days. Although being a defined investigation, there was no prelim report published within 30 days (IE breach of ICAO Annex 13).

The intriguing aspects of this investigation are how this incident, without any injuries or damage to the aircraft, became the subject of a full blown defined investigation??

The answer I believe is contained in the identified safety issue: https://www.atsb.gov.au/safety-issues/AO-2022-007-SI-01

This safety issue has led to the ATSB issuing a very rare safety recommendation.. :

Action description

The ATSB recommends that Eastern Air Link address the safety issue, through provision of guidance and training to flight crew concerning the safest option in the selection of an approach method when weather conditions are marginal for the conduct of a visual approach.

Hmm...this bit reads more like the observations and actions that should fall inside the remit of the regulator (IE issuing of an RCA)?

ATSB comment

The ATSB acknowledges Eastern Air Link’s changes to the 3 NM limit for manoeuvring for a straight-in approach, but notes these were actioned through notice only with no supported training. Consequently, the ATSB examined flight crew actions during approaches into Lord Howe Island during a period of potential marginal weather conditions on 3 February 2023. While the weather conditions at that time did not qualify as being marginal for a visual approach, the data was mixed, with 2 of the 4 arrivals positioning for a straight-in approach while within the 3 NM manoeuvring limit. This prompted a request for further clarity on how the proposed changes were being implemented as the non‑adherence to the operational change indicates that, without any attached guidance or training component to emphasise and support the change, its implementation had been ineffective.

The changes to the stabilised approach criteria, and the later advice on the intention of this change, also required closer examination. In guidance on the appropriate response to deviation from stabilised approach criteria, the Flight Safety Foundation recommends that:

If the approach is not stabilized before reaching the minimum stabilization height, or if any flight parameter exceeds deviation limits (other than transiently) when below the minimum stabilization height, a go-around must be conducted immediately.

Transient deviations from stabilised approach criteria are generally accepted when turbulent conditions exist, whether the result of weather or the effects of local terrain, although should conditions result in serious deviation, the safest option is to go around. A transient deviation acceptance could be read into the content of 2C6.6.2, with the statement that ‘only minor corrections to speed and flight path, to maintain a stable approach, should be required…’ however, both this text, and the new note raised the question of what is required where more serious deviation results. The note gives no indication of transient exceedances being the issue but permits intentional exceedance of stabilised approach criteria should conditions necessitate, if that exceedance was foreseen through a special briefing. However, the ATSB notes that:

• The stated ‘self-briefing’ component is not apparent from the text.
  
• There is no guidance on what is considered a safe deviation from these criteria. As stated, the text permits an unrestricted authorisation to deviate from the standards.
  
• The operator has not introduced a monitoring or reporting component to this authorised deviation.
  

The stabilised approach method, and the well-established limits therein, has resulted in a significant reduction in loss of control and collision with terrain accidents during approach and landing. This method and the associated limits are recognised and followed globally and operate successfully in environments that present the possibility of conditions more extreme than that presented by Lord Howe Island, and without the need for acceptance of deviation. Further, this modification to the note following the stabilised approach criteria has the potential to validate the manoeuvring conducted during the occurrence event, as well as introducing the potential to significantly increase risk where meteorological conditions exist to justify extreme breaches of stabilised approach criteria.

In summary, the ATSB considered that Eastern Air Link’s initial response and the associated safety action did not address the safety issue. Therefore additional information was sought from the operator.

MTF...P2 

[Peetwo]

No.43 from the list completed?? -   

Another 'Short' AAI (ie no requirement for a ICAO Annex 13 prelim I.E. We've got a notified difference for that...  ) completed with yet again another pointless word shopped media release, from this week's (attributed to) DTS Stewie (stating the Ducking obvious) Macleod ...  :

R44 pilot unable to recover from unanticipated yaw prior to Forresters Beach accident

Back to top

A NSW Central Coast helicopter accident highlights to pilots the need to be cognisant of factors that can induce unanticipated yaw, according to an Australian Transport Safety Bureau investigation report.

On 19 November 2022, the pilot of a Robinson R44 was conducting a private flight with two passengers to a function centre at Forresters Beach from a nearby property.

During the approach to the planned landing site, a carpark beside the venue, the pilot reported experiencing an uncommanded yaw to the right, which was unable to be recovered.

“During the approach to the confined carpark landing site, the helicopter experienced an unanticipated yaw to the right,” ATSB Director Transport Safety Stuart Macleod said.

“The pilot’s response was ineffective at recovering control – however the unanticipated yaw may have occurred at a height from which control of the helicopter was not recoverable.”

The helicopter subsequently struck powerlines before impacting the ground. While the helicopter was substantially damaged, fortunately the occupants received only minor injuries.

Considering Gosford weather observations of a north-east wind at 10 kt, the approach track placed the wind from a direction and at a speed known to be conducive to the onset of unanticipated yaw, the investigation notes.

“It’s important for helicopter pilots to remain cognisant of the factors that can induce unanticipated yaw, especially the relative wind direction,” Mr Macleod said.

“These factors should be avoided, or their influence on the helicopter’s anti-torque system should be managed through positive control of the yaw rate. Depending on the yaw rate recovery may not be immediate, but maintaining the recovery control inputs is the most effective way to stop the yaw.”

Read the report: Collision with terrain involving Robinson R44, registration VH-TKI, at Forresters Beach on 19 November 2022

MTF...P2 

[Peetwo]

ATSB Safety Message: Popinjay an agent for Vans Aircraft -   

Via PJ HQ:

Van’s Aircraft owners urged to consider retrofitting new engine mount nose gear system

The ATSB is urging Van’s Aircraft owners to consider retrofitting a stronger nose gear and engine mount system on RV-6A, RV-7A and RV-9A models, after a number of notable nose-over accidents.

In January a Van’s RV-9A encountered a tailwind during landing on a private grass airstrip on French Island, Victoria, resulting in a hard landing. The aircraft bounced, and its nose gear then collapsed. The aircraft subsequently nosed over, and came to a rest inverted, resulting in serious injuries to both occupants, and substantial damage to the aircraft.

The accident was similar to a few others, including one investigated by the ATSB in 2017. In that accident, the nose gear of a Van’s RV-6A collapsed after the aircraft bounced during a heavy landing on a dirt airstrip in north Queensland.

In light of these accidents, the ATSB is urging owners and operators of Van’s RV-6A, RV-7A and RV-9A aircraft to consider Van’s Aircraft Service Letter 19-04-30.

The service letter details options and instructs a method for retrofitting older aircraft with a new style of engine mount/nose gear system, designed similarly to the engine mount and nose gear found on the newer RV-10A and RV-14A models.

“While touching down on the nose landing gear should be avoided, the newer nose gear design has been developed with stronger shock absorption, which should reduce the likelihood of nose-over accidents,” ATSB Manager, Transport Safety Derek Hoffmeister said.

“If you haven’t already, I would urge you to consider retrofitting the new nose gear and engine mount to your RV-6A, RV-7A, and RV-9A aircraft.”

Read the Van’s Aircraft Service Letter: www.vansaircraft.com/service-information-and-revisions/sl-19-04-30/

Publication Date
16/06/2023

A P86 comment in reply, via BRB email chains:

P86: It’s an interesting post. It’s good to see technical improvement, but strangely, there isn’t one mention of CASA here. Aren’t they responsible for airworthiness?

Also, the terminology used here - “urged” and “consider”?? Does this mean the certified components are unsafe?
Is an “urge” how we manage safety now?  ICAO use “should and shall”, “urge” isn’t part of the vernacular!

This may be pedantic, but it’s a good example of how these independent bodies don’t work together when they should - technical advice, documented by the NAA and disseminated by the appropriate body.

https://www.linkedin.com/posts/australian-transport-safety-bureau_vans-aircraft-owners-urged-to-consider-retrofitting-activity-7075274922398285824-UI0K?utm_source=share&utm_medium=member_ios

I would add, why has it taken the ATSB 6+ years after the Starke ALA accident and 3 years after Van's Aircraft issued their suggested service letter - HERE - to join the dots and make the above OBS? Also consider that the mentioned January incident is apparently not being investigated by the ATSB...

ASN Wiki reference: https://aviation-safety.net/wikibase/306096

MTF...P2 

[Kharon]

HOI! Cloth ears....

Perhaps, when someone (like the 'minister') gets a break from the 'land rights for gay whales' campaign; or, defining how aircraft can fly without fuel; or, afford to operate into the few aerodromes we have left which provide air traffic separation; there may be some time left over to read the IATA calls on 'government' to actually comply with the convention they signed up for. The statements below and the NTSB discussion are pertinent (in the extreme) to our very own ATSB.

“The accident investigation process is one of our most important learning tools when building global safety standards. But to learn from an accident, we need reports that are complete, accessible and timely,” said Willie Walsh, IATA’s Director General.

Can the minister provide one example of an ATSB report which meets the criteria W. Walsh needs to advise his organisation on how to adopt 'best practice'. The short answer is a resounding NO.

“The requirements of the Convention of International Civil Aviation (Chicago Convention) Annex 13 are clear. States in charge of an accident investigation must:

Submit a preliminary report to the International Civil Aviation Organization (ICAO) within 30 days of the accident

Publish the final report, that is publicly available, as soon as possible and within 12 months of the accident.

Publish interim statements annually should a final report not be possible within 12 months.”

Not only has ATSB failed to meet the requirement of 'the Convention' but the majority of 'reports, when finally published are too little and too late to prevent repetition; unless directed to the operator 'safety system' who are left to cure problem, internally, which is about as much use to the industry as three men away from home at harvest time. 

“Over the past five years, fewer than half of the required accident reports meet the standards for thoroughness and timeliness. This is an inexcusable violation of requirements stated clearly in the Chicago Convention. As an industry we must raise our voice to governments in defence of the accident investigation process enshrined in Annex 13. And we count on ICAO to remind states that the publication of a complete accident report is not optional, it is an obligation under Annex 13 of the Chicago Convention,” said Walsh.

Australia's response has been to appoint the 'Wee bearded Popinjay' as the face of air accident investigations; and, if you can stomach it, take a look through the waffle and 'junk' analysis produced by the many 'directors' creeping about the corridors we pay great sums of tax dollars to. Dolan, then Hood and now the camera hungry Popinjay. Inutile; in any sense other than 'top cover' and bound and subservient to CASA through the MoU. Professional 'investigators' across the planet shake their heads and roll their eyes toward heaven when the ATSB is mentioned. Many actually just look away, shuffle their feet and change the subject.

The questions for the minister are; why are some of our best and brightest working anywhere else but for the ATSB? – and why the procession of 'amateurs' is allowed to exist?

Toot toot.....

[Peetwo]

Popinjay releases DFO cover-up report: Verdict - "Nothing to see here!" -   

Via PJ HQ:

ATSB releases safety study into aerodrome design standards and the Bulla Road Precinct development at Essendon Fields Airport



An ATSB safety study investigation’s findings contain important lessons for safety assurance in airport planning and safeguarding. It reviews the interpretation and application of Australian and international aerodrome standards, which affect how high and how close buildings can be placed to a runway.

The investigation examined historical uncertainty around the application of the aerodrome standards, and resolution by the Essendon Fields Airport operator of ‘grandfathering’, with the acceptance of the Civil Aviation Safety Authority (CASA), to aerodrome standards from the 1970s. Those standards had been used to determine the width of the runway strip (the rectangular surface area surrounding the paved runway) for the east-west runway 08/26. This action also determined the location of the obstacle limitation surfaces (OLS) along the side of the runway strip. The planning and approval process for the Bulla Road (DFO) retail precinct at the airport in the early 2000s was considered in the context of that historical uncertainty.

“This complex investigation made nine findings pertaining to the acceptance of grandfathering in non-standard circumstances, review of safety cases, limited guidance for some safety standards, and assurance processes between federal agencies for airport planning relating to the Bulla Road Precinct,” said ATSB Chief Commissioner Angus Mitchell.

“We note that both CASA and the airport operator have maintained that there is an acceptable level of safety with the current status of the runway strip, obstacle limitation surfaces, and publication of information to pilots. It was not the role of the ATSB to do a separate risk assessment, but we have noted the type of risk information that should be taken into account by aerodrome operators and regulators.”

Mr Mitchell explained that the OLS are imaginary surfaces that provide a protective buffer against obstacles, such as buildings, for aircraft in the final stages of the approach to land. Any obstacles that encroach the OLS are subject to a referral to the aviation regulator for risk assessment.
From 1971, when Essendon ceased operating as an international airport, the runway 08/26 strip width was changed from 300 metres to 180 metres. The OLS around it changed with this dimension as well. The strip width was consistently published as 180 metres. However, in 2015, CASA issued an instrument to approve obstacles and require the strip width be published as 300 metres when the standards for the 180 metre strip width were not identified. The effect was that the northern portions of the retail centre buildings (which were built in 2005) infringed the runway strip and OLS down the side of the runway strip. They were notified to pilots as obstacles.

Mr Mitchell explained that the ATSB’s investigation commenced in 2018 after questions arose in another investigation as to how the buildings came to infringe the OLS. In 2019, when standards from the 1970s were identified and grandfathering occurred with the publication of a 180 metre runway strip width, the retail centre no longer infringed the runway strip or OLS.

Mr Mitchell said that the investigation had been through extensive review processes with directly involved parties, and was rescoped when grandfathering provisions were applied during the course of the investigation. Further, there were challenges with the limited information available from historical periods stretching back to the 1970s to provide context to the investigation and the need to address varying interpretations of the standards.

Separately, but in parallel to this investigation, an International Civil Aviation Organization (ICAO) taskforce has been reviewing the international standards (from which the Australian standards are derived) for the OLS. Changes have been proposed with consideration of the need to provide greater clarity on the application of the surfaces, and to reflect that modern aircraft and navigation systems have enabled reduced deviations from the intended flight path. Contracting States like Australia are considering the proposed changes.

“This investigation highlights the complex nature of airport planning and aerodrome safeguarding with the many factors that need to be considered to ensure an acceptable level of safety,” Mr Mitchell concluded.
“Aerodrome planning and aerodrome safeguarding can be further complicated when applying aerodrome standards with changing design criteria over a long historical period, as was the case at Essendon Fields Airport. It is even more challenging when there are incomplete records, limited guidance on how design criteria relate to risk, and changing interpretations of standards.”

Read the report: Aerodrome design standards and the Bulla Road Precinct development at Essendon Fields Airport, Melbourne, Victoria

Publication Date
30/06/2023

 
Finally, after 5 years 4 months and 2 weeks, Popinjay releases a Final Report with 146 pages of technical and bureaucratic waffle. IMO they could have saved the paper and expensive bureaucratic resources and simply referred to the following:

Obviously designed to put the reader into a coma after the first 20 pages or so... There is lots in there that really needs to be dissected and properly interpreted. However even after a skim read it becomes obvious that the report is cleverly layered to obscure the bigger safety issues at hand and ultimately dodging the bureaucratic mea culpa fact that the building of the DFO should never have been approved in the first place...  

Here is the one safety issue generated from this report... : Ref - https://www.atsb.gov.au/safety-issues/AI-2018-010-SI-04

Note that this safety issue was apparently released today, yet the department of Infrastructure has already actioned this safety issue dating back to 2020:

Action description
As a result of this investigation, the Department of Infrastructure, Transport, Regional Development and Communications advised the ATSB on 13 February 2020, that the following safety action had been taken:

The Airports Act 1996 (the Act) establishes the requirements for the Minister’s decision on Master Plans and Major Development Plans (MDPs) to have regard to the views of the Civil Aviation Safety Authority (CASA) and Airservices Australia (Airservices) in so far as they relate to safety aspects and operational aspects of the plan (specifically ss. 81(3)(d) and 94(3)(e) respectively).

The Department acknowledges the views of CASA were not included in the Bulla Road Precinct MDP submitted to the Minister for consideration in 2004. However, the Department’s method of mitigating risk from not receiving the CASA advice within the statutory timeframe was to recommend a condition be imposed on the development. This condition required Essendon Airport Pty Ltd ‘to consult with CASA during the construction of the proposed development and comply with any safety requirements specified by that agency’. Underlined worked out really well?? - 

The Department’s MDP process now includes an arrangement with CASA and Airservices for seeking advice on safety in accordance with the requirements under the Act. A specific format for receiving these views in the assessment of MDPs is not prescribed in the Act. This ensures advice from CASA and Airservices is in a format that is flexible and fit for purpose.

The Department has received confirmation from CASA and Airservices of their ongoing commitment to provide safety and operational advice on Master Plans and MDPs. The Department will continue to work closely with CASA and Airservices to ensure the existing approach remains fit for purpose.

I was also bemused that given AusALPA's high profile media campaign and related Parliamentary submissions in this matter, that the ATSB did not include the combined Pilot association as a DIP to the investigation?

Perhaps this 2020 AusALPA MR might help explain why:

Via AusALPA:

AusALPA Media Release: 16 September 2020

SHOPPING CENTRES MORE IMPORTANT THAN AVIATION SAFETY:

Australia’s Professional Pilots respond to the ATSB investigation update into the approval process for Bulla Road Precinct at Essendon Fields Airport

On the 21st of February 2017, a Beechcraft King Air crashed into a building that is part of the Essendon Airport Bulla Road retail precinct, tragically killing all five occupants on board.

This accident has put a spotlight on why a shopping centre was built closer to one of Essendon Airport’s runways than international standards allow.

  

The Australian Transport Safety Bureau (ATSB) has released a progress update to itsinvestigation: “The approval processes for the Bulla Road Precinct Retail Outlet Centre”, Investigation Number: AI-2018-010.

AusALPA believes that deep and latent safety problems exist in the system of airports regulation where aviation safety considerations are made secondary to development objectives. AusALPA asserts that the regulatory system is flawed due to an inappropriate bias that mandates that development proposals or airspace penetrations must be granted unless almost impossible to achieve risk thresholds are breached.

AusALPA hopes that the final report also addresses other related matters that have occurred at Essendon since the commencement of this investigation, AusALPA calls for the establishment of a high level Government Review to address the safety and economic regulation issues of Australia’s airports with an aim to genuinely reform airspace protection and other operational safeguards at Australia’s airports.

Background

AusALPA is the Member Association for Australia and a key member of the International Federation of Airline Pilot Associations (IFALPA) which represents over 100,000 pilots in 100 countries. We represent more than 7,500 professional pilots within Australia on safety and technical matters.

AusALPA is committed to protecting and advancing aviation safety standards and our membership places a very strong expectation of rational, risk and evidence-based safety behaviour on our government agencies and processes.

--- END ---

 

Finally take note of this extract from figure 26 of the FR:



Note that despite the runway width changing (IE 180 to 300m) the legal parameters for the OLS transitional surfaces (IE 1 in 7 slope) throughout history, since the 2004 Ministerial MAP approval, that the building line of the DFO was still cynically built to within millimetres of the 1 in 7 transitional surface. This was also the case for runway 17/35...

The view across to the DFO building wall on the day of the B200 fatal crash:



MTF...P2 

[Peetwo]

Finally MSM catch up on Essendon DFO cover-up report?? -     

Courtesy that man Hatch, via the Age/SMH.. : 

DFO plane crash inquiry finds confusion over buffer zone with airport

By Patrick Hatch
July 17, 2023 — 5.17pm

An investigation triggered by the fatal DFO crash six years ago has found the private operator of the neighbouring Essendon Airport largely ignored modern safety standards about how close the shopping centre could be built to the runway.

But uncertainty around rules from the 1970s on how close buildings can be to runways, and an updated version of the code, meant the Australian Transport Safety Bureau (ATSB) could not find that the Direct Factory Outlet shopping centre should not have been built where it is, and it does not say it is unsafe.



Workers at the scene in 2017 of the plane crash at the DFO shopping centre in Essendon. JUSTIN MCMANUS

The bureau’s report also details the airport’s push to open up as much space for property development as possible by applying the outdated standards, which some pilots say is emblematic of how commercial buildings are encroaching on safe aviation operations at airports nationwide.

The safety regulator launched an investigation in 2017 into how the DFO building off Bulla Road was approved after a Beechcraft King Air crashed into the building’s side on February 21 that year, killing pilot Max Quartermain and his four passengers. In 2018, the ATSB found pilot error was to blame for the crash.

While investigating the crash, the ATSB discovered the DFO was within 150 metres of the southern runway, in an apparent breach of safety standards in place since 1987, which mandated a 300-metre “strip width” on such a runway, or a 150-metre buffer zone on each side.

The safety authority found the location of the DFO did not contribute to the crash, which happened on the building’s southern end. But the bureau was sufficiently concerned to launch a separate investigation into how the building was approved and built in 2005.

Essendon Airport

How the DFO flew in the face of modern airport rules



The DFO was one of the first buildings constructed around the airfield after the airport property was leased from the Commonwealth in 2001 for $22 million for a 99-year tenancy.

By 2016, Essendon Fields Airport management said the entire operation was worth $1 billion, having developed a hotel, car dealerships, retail outlets and other commercial buildings. Two small airlines, charter operators and emergency services still use the airport.

Essendon Airport reduced its strip width from 300 metres to 180 metres in 1971 when international flights moved to the new Melbourne Airport at Tullamarine, and that information was given to pilots to inform safety and operational decisions.

The ATSB’s final report into how the DFO was approved was published on June 30 – almost six years after launching the investigation – and it found that it was “unlikely” the airport “adequately determined” it was still able to use the 1970s standard when it submitted its plans to the federal government for the new DFO retail precinct in 2004.

Five people have been killed after a light charter plane crashes into a DFO shopping centre shortly after taking off from Essendon Airport, in what is being called Victoria's worst air disaster in 30 years. (P2 - Not Fairfax article video)

Although rules for using “grandfathering” provisions – where the airport could continue to apply the 1970s standards – were “open to different interpretations”, the ATSB said it could find no evidence the Civil Aviation Safety Authority (CASA) had given the airport a concession to use that 180-metre clearance zone.

The bureau’s report says that in 2003, the airport’s management and CASA were discussing compliance with the modern rules, which made it “very unlikely the [older standards] had been identified at the time as the applicable standards”.

Captain Marcus Diamond, a safety and technical manager at the Australian Federation of Air Pilots, said the ATSB report largely agreed with the federation’s concerns that the airport ignored regulations intended to protect aviation activity and safety.

“The DFO should not have been built within the 300-metre strip width, which was the standard at the time and still is,” Diamond said.

He said pilots were increasingly concerned about overdevelopment at airports around the country. Airports are leased out on the condition that tenants prioritise aviation operations.

“We’ll be calling for the government to put stricter processes in place ... so we’re assured of protection of the aerodrome operations and that they’re not impinged by inappropriate buildings,” Diamond said.


Firefighters at the scene of the 2017 crash. JASON SOUTH

The ATSB investigation details a 2003 email it uncovered, in which an Essendon Airport management officer advised that CASA had agreed verbally to the airport applying a strip width of 180 metres rather than 300 metres.

“This should open up about 36,000 square metres of new land for development,” the email says.


Pilot Max Quartermain (left) and passengers Russell Munsch, Glenn Garland and Greg De Haven were killed in the crash. SUPPLIED

Essendon Airport relied heavily on a letter from a CASA officer confirming that interpretation a month later, but CASA told the ATSB investigation that advice was wrong and had no legal validity.

A CASA internal briefing from around the time the federal minister was approving the development plan said it would be difficult to justify reducing the strip width “especially for economic development reasons”.

AIR ACCIDENT
Pilot error to blame for Essendon DFO plane crash, report finds

Essendon Fields Airport declined to comment.

ATSB chief commissioner Angus Mitchell said the safety authority’s investigation did not find that the DFO was unsafe or should not have been built, but the bureau could not confirm how the airport determined the development was compliant with the rules.

“We can’t say it was in breach, or it was in accordance, because of that uncertainty of what standard applied and what was being used at the time,” Mitchell said.

The final report only identified one safety issue, which is that the federal Department of Transport did not have an agreed assurance framework with CASA for assessing airport development plans.

CASA made findings in 2012 and 2014 that the 180-metre Essendon runway strip was not compliant. In 2015, CASA ordered the airport to notify airport users that the runway had a 300-metre strip while identifying “approved obstacles” including the DFO within that area.

In 2019, the airport used “grandfathering” provisions to revert the runway back to a 180-metre strip, which CASA accepted, meaning the DFO was no longer identified as an obstacle.

How the Essendon DFO plane crash happened



However, the ATSB found the airport and CASA “did not consider all the relevant risk information” when making that decision and “greater safety assurance could have been provided”.

Diamond said the reduced length of the runway had downgraded Essendon’s status as an airport because some operators chose not to use the lower category of runway with bigger aircraft.

The ATSB’s investigation is one of the longest it has undertaken, with three draft reports prompting extensive challenges from the airport and CASA.

A CASA spokesperson said the agency “remains satisfied” the DFO did not breach the runway clearance area, and “that the development was safe and compliant when it was approved and remains safe and compliant”.

Quartermain was to fly passengers Greg De Haven, Russell Munsch, Glenn Garland and John Washburn to King Island for a golf trip.

A coroner’s report released last year repeated the ATSB’s finding that the crash was caused by the aircraft’s rudder trim being left in a “full nose left” position before takeoff. Quartermain also did not conduct necessary pre-flight checks.

MTF...P2 

[Kharon]

Perhaps, not so elementary.

"When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth".

Conan Doyle scripted that remark for Holmes; and, broadly speaking it has validity; however, much depends on the ability to define and eliminate ALL impossibilities, and to qualify that which is 'improbable'. Don't mind me; (ramble follows – ignore as pleases). But, the curse of curiosity keeps dragging me back to the Essendon event and the ATSB reporting of the same.. Indeed, every time the event is mentioned (at BRB last for example) the persistent 'nagging' from an as yet undefined element drags me back to the event. A thinking 'out loud' scribble follows. There are three triggers to these ruminations; to wit, the previous events at Mt Hotham; the unseemly, hasty, unwarranted attendance of Hood on scene; and, potential for contamination; and, the lack of analysis of the first 'point of contact' the aircraft had with the 'wall' before collision with the building proper.

Something went seriously astray at Mt Hotham; the potential for a serious event writ large and clear. Experienced pilots (even the not so much) could and would have resolved the 'problems' defined and have been very (very) situationally aware. The 'flight path' and actions taken beg serious questions. The 'What happened' paragraph from the ATSB report into the Hotham event – HERE – should have raised some very serious concerns, worthy of 'deep' examination. Alas.   

A little in-depth reading and digging (dry stuff) presents some interesting data. Beyond my remit, but (IMO) could have been given a little more consideration than the  ATSB report into the Essendon event provided. FWIW – from a broad range of articles, some possible effects of diabetes medication - HERE.

“The pilot’s CASA medical records indicated that he was diagnosed with Type 2 diabetes in 2007. At the time of the accident, the pilot was reportedly on multiple oral medications to manage his diabetes and was considered to have met the CASA requirements for maintaining his medical certificate.”

A curiosity which has always troubled was the very rapid arrival of Hood 'on site' and the quick pronouncement that it was pilot error and the rudder trim was incorrectly set; well that and some speculation about power lever roll back (bollocks). Which takes us to the curiously intriguing elements of the actual analysis. For example:-

ATSB - “Analysis of the roof impact marks and CCTV footage showed that the aircraft had contacted the concrete parapet wall on the right side of the empennage before exiting the roof of the building. It was likely that the impact with the wall caused the abrasion damage to the empennage and rudder.”

Old Sir Issac Newton came up years ago with a notion which has been tested and proven many times. Consider the forces involved – the right side of the aircraft thumped the parapet wall. 'Likely that the impact with the wall – etc – Rudder. No shit Sherlock. F=MA; + for every action (force) in nature there is an equal and opposite reaction.  Could it be possible that the first impact with 'the wall' damaged a little more than the elevator – considering the location of the cables and etc? The detailed airframe schematic is a handy reference. 

Then; there's this little gem to consider:-

ATSB - “Both the left and right elevator trim actuators were found in a position that equated to a full nose‑up trim position. Witnesses, CCTV and ADS-B evidence either opposed or did not support ZCR having full nose-up trim at take-off. It is possible that the elevator trim was moved to this position by the pilot in an attempt to control the aircraft’s flight path or the trim may have moved as a result of impact forces. The ATSB determined however, that it was unlikely that the elevator trim was in the full nose-up position at take-off and did not examine the trim tab actuators any further in order to confirm their position at impact.”

Aye, indeed all food for thought; now, I ain't calling out conspiracy or dark murky doings; not at all, but the ATSB report and subsequent proceeding have all seemed a little 'shallow' – scripted in haste more than for nefarious reasons. As stated, curiosity a curse aligned with an itch I just can't scratch. Ignore the fool's rambling attempts to be rid of the incubus..I shall say no more..........

Toot – toot....

[Peetwo]

AO-2022-031: Short Investigation Final Report release -   

Announced yesterday by this week's DTS Stewie Macleod:

Unrelated technical failures in Dash 8 runway excursion highlight how unexpected events can combine to produce undesirable outcomes


A combination of unrelated technical failures affecting directional control contributed to a Dash 8 aircraft veering off a narrow, relatively short runway towards the end of its landing roll, an ATSB investigation report details. 

The Skytrans Dash 8 (DHC-8) was operating a scheduled passenger flight with three crew and 26 passengers on board from Brisbane to Chinchilla, in Queensland’s Western Downs, on 23 May 2022.   

Due to a right engine control unit (ECU) failure observed just prior to the top of descent, the flight crew were unable to use reverse thrust from that engine to aid deceleration during the landing, and they intended not to use reverse thrust from the left engine to avoid asymmetric thrust.  

After conducting a straight-in approach, and with a tailwind (within acceptable limits), the aircraft touched down further along the runway than intended, but probably within the company’s permitted touchdown zone. The flight crew advised that at the time of landing, they anticipated that aircraft braking would be at or close to normal. 

“The crew then experienced reduced braking effectiveness after touchdown, when the anti-skid system activated after the outboard right main wheel locked up,” ATSB Director Transport Safety Stuart Macleod said. 

Due to the lock-up, the anti-skid system released brake pressure on the outboard wheel on both main landing gears, extending the landing roll. 

“While assessing the available braking performance, the flight crew missed a standard call that would have prompted the captain to transition to using the tiller in order to provide directional control via nosewheel steering as the aircraft decelerated.” 

In an attempt to slow the aircraft, the captain applied reverse thrust on the left engine, which produced asymmetric deceleration resulting in the aircraft veering slightly left. 

“The captain then elected to use the emergency brake to slow the aircraft. Due to the runway being narrow, the left wheels departed the sealed runway surface in the final stages of the landing roll.” 

After stopping on the turning pad at the end of the runway, the flight crew taxied the aircraft to the apron via the taxiway.  

The flight crew’s decision to continue to Chinchilla after observing the ECU failure was consistent with guidance in the operator’s procedures, the investigation found. 

However, the investigation identified that the procedures permitting the crew to continue the planned flight after the ECU failure did not include consideration of other factors that could increase the required landing distance, including a tailwind and a damp runway, or that a narrow runway increased the risk of a veer off due to asymmetric thrust. 
 
The aircraft operator has subsequently updated their procedures for continued flight following an ECU failure, prohibiting the use of a narrow runway unless operationally required in an emergency. 

Revisions to the operating procedures also prohibit the use of short runways with a tailwind. 

“This incident highlights that unexpected events can combine to produce undesirable outcomes,” Mr Macleod said. 
“As such, procedures for managing an equipment failure should consider factors that may influence performance or other operational considerations. 

“Increased safety margins in procedural documentation can help ensure flight crew make appropriate decisions when managing unexpected events.” 

Read the report: Runway excursion involving De Havilland Canada DHC-8, VH-QQB, at Chinchilla Airport, Queensland on 23 May 2022 

Publication Date
11/10/2023

Not sure why the Popinjay crew thought it necessary to announce the final report publication, of occurrence (short) investigation AO-2022-031, with yet another bollocks DTS press release, instead of letting the report speak for itself? However I do note that for a 'short investigation' this report had no prelim report attached (exempted by notified difference to ICAO Annex 13), no interim report on the anniversary date and took 16 months and 18 days to produce what appears to be a fairly rudimentary desktop investigation, with the identified safety issues addressed internally through the operator's SMS within weeks of the occurrence.

Maybe the following explains some of the delay:

Submissions on that draft report were received from:

the flight crew of VH-QQB
Skytrans Pty Ltd
DeHavilland Aircraft of Canada Limited
Civil Aviation Safety Authority

After changes, a revised draft report was provided to the directly involved parties.

Submissions on that draft report were received from:

Skytrans Pty Ltd
Civil Aviation Safety Authority

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

Hmm...could it be the CASA tech staff (stretched to the limit) took inordinately long length of time to reply to the 2nd draft; or maybe there was some conflict between the operator and the regulator given the obvious friction over the Torres Strait Island aerodrome restrictions imposed by the regulator under Part 139?? Ref:  Dots-n-dashes on Su_Spence stating the bollocks media pages?? &  Su_Spence to the rescue on Torres airfield embargo?? - Yeah right!

MTF...P2 

[Peetwo]

AO-2019-041 Systemic Investigation Final Report - Popinjay to the rescue??

Via PJ HQ:

Flight paths redesigned after close proximity incident

Flight path design should minimise the potential for conflict and the need for interventions, an ATSB investigation into a close proximity event at Sydney Airport highlights.

The investigation report details that in the early evening of 5 August 2019, a Qantas Boeing 737 was on approach to land on Sydney Airport’s runway 34 right, while a Qantas A330 was awaiting a clearance to line up and take off from the same runway.

After a Dash 8 which had just landed had taxied off the runway, the aerodrome controller in the Sydney air traffic control tower – a qualified controller under training for the aerodrome controller role under the supervision of an instructor – issued the A330 with a clearance for an immediate take-off.

The A330 flight crew complied with the take-off instruction, but the controller, assessing that there could be insufficient runway separation between the departing A330 and the landing 737, then instructed the 737 to go around.

The 737 flight crew initiated the go around by climbing on the runway heading, but did not make a right turn when climbing through 600 ft as required by the missed approach procedure.

About 10 seconds later, the controller instructed the 737 to turn.

Meanwhile, as cleared, the A330 followed the standard instrument departure track by turning right shortly after take-off.

The two flight paths began to converge, with both aircraft turning right and climbing, and the A330 flight crew received a traffic alert from the onboard traffic collision advisory system (TCAS). Shortly after, the A330’s first officer sighted the 737 behind and to the right in a climbing turn.

“The aircraft came into close proximity, with separation between the aircraft reduced to about 0.42 NM (or 800 m) laterally and about 508 ft (or 150 m) vertically,” said ATSB Chief Commissioner Angus Mitchell.

“Nevertheless, the controllers maintained sight of both aircraft throughout the sequence and the risk of a collision was low.”



The ATSB’s investigation found that the close proximity incident was the culmination of a series of events that, individually, would only be minor concerns, but collectively resulted in a serious incident.
That series of events included:

• Reduced spacing between arriving aircraft without coordination between controllers;
  
• The 737’s speed during some of the final approach was higher than allowed without the flight crew advising the controller;
  
• The controller's and instructor’s mental models of the developing traffic situation did not fully account for the effects of the 737’s delayed and relatively wide turn, and they expected the A330’s flight path to be further from the 737;
  
• No safety alert or avoiding action advice was given to either flight crew to notify them of their proximity and increase their situational awareness;
  
• The controller did not modify the A330’s flight path, which would have increased the distance between the aircraft;
  
• And, mindful that the trainee controller was (at this stage of their training) meant to be demonstrating the ability to work without intervention, the instructor did not provide effective prompts or intervene.
  

“The ATSB found that because the respective departure and missed approach procedures both involved climbing from a low level and heading to the east, controller intervention was needed to maintain separation,” said Mr Mitchell.

“In addition, controllers at Sydney did not have procedural controls to draw upon to separate aircraft in this type of situation when it occurred at low altitudes and at night.”

The ATSB identified three safety issues relating to the procedures and controller training, as well as another safety issue relating to the use of operational risk assessments for specific scenarios.

In addressing these issues, in 2020 Airservices redesigned the missed approach procedure for Sydney Airport’s runway 34 right to improve separation with other aircraft departing on a standard departure track from the same runway.

During the investigation Airservices also added compromised separation scenarios involving aircraft at low altitudes at night to the Sydney tower controller instructor guide, while in 2023 Airservices advised that the training program also now included a missed approach with a preceding departure in instrument meteorological conditions.

Qantas, meanwhile, updated the missed approach coding in its 737 flight management computers, incorporated related scenarios into cyclic training sessions, and updated its flight data analysis program to more closely monitor approach speeds and traffic collision avoidance system data.

“In this occurrence, a series of individual errors and decisions made by flight crews and controllers gradually reduced margins to a point where the two aircraft came within close proximity.” Mr Mitchell concluded.

“Although events like this are uncommon, systems should be designed to minimise the likelihood of a more serious outcome.”

Publication Date
12/10/2023

This 'systemic' investigation did have a prelim report that took 7 months to produce and the final report that has taken 4 years, 2 months and 7 days to complete but does not appear to have annual interim reports associated with it. And is now announced having being completed by an absolutely 'know nothing' bureaucrat in a pre-fabricated weasel worded presser that has zero value to any associated industry stakeholders - UDB!...

MTF...P2 

[Peetwo]

AO-2022-058 FR: Popinjay to the rescue issues SRs - WTD?

Remember this post from the top of the page (pg 17)? - Proof of ATSB delays and ICAO Annex 13 non-compliance??  

Well kudos to PJ's crew having completed yet another investigation off that list within one year (345 days)??   

At the same time they have issued two (very rare) safety recommendations, both addressed to the operator?? 

The (attributable to) PJ 'bollocks' presser:

Safety recommendations issued after Saab 340 taxied for flight with horizontal stabiliser bung not removed



The Australian Transport Safety Bureau has issued two safety recommendations following an incident where a horizontal stabiliser bung was not removed from a Saab 340 regional airliner prior to taxi at Cairns Airport.

On 16 November 2022, the Regional Express operated Saab 340B was taxiing for take-off from Cairns for a scheduled passenger flight to Bamaga, Queensland, when an engineer on a nearby parking bay noticed something hanging from the aircraft, and contacted the tower.

The air traffic controller visually confirmed the engineer’s observation and alerted the crew, who returned the aircraft to the bay.

“To prevent bird nesting, the operator required its aircraft parked overnight in Cairns to be fitted with a bung installed in each of the two horizontal stabiliser trim actuator coves,” ATSB Chief Commissioner Angus Mitchell said.

At interview, no members of the ground crew and flight crew involved in the pre-flight checks recalled seeing either of the bungs installed, nor the tether which connects the two, which has a ‘remove before flight’ conspicuity flag in the middle.

An inspection conducted once the aircraft returned to the bay identified the bung was still installed in the left trim actuator cove, with the rest of the bung assembly hanging from it.

“The horizontal stabiliser bungs were most likely incorrectly installed – or possibly the tether rope with the ‘remove before flight’ flag was not hanging from the horizontal stabiliser as designed – resulting in them not being detected during pre-flight preparations and the aircraft being dispatched with the bung installed,” Mr Mitchell said.

“Targeted inspection of locations and components, rather than relying on flags which may not always be visible, can help identify when these covers or devices have not been removed.”

The ATSB’s investigation found the operator had no formal procedures for the storage and accountability of the bungs after they were removed from the aircraft.

It also found the design of the bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight. 

The investigation notes the operator has commenced a risk assessment to formalise the procedures around the use of the horizontal stabiliser bungs, and to support this, an engineering order was developed to document and approve the manufacture of the bungs.

“However, these actions do not address the issues around the storage and accountability of the bungs when they are removed or the aspects around the identification of an installed bung or the safe operation of the aircraft if the bungs were not removed,” Mr Mitchell noted. 

As such, the ATSB has issued Regional Express two safety recommendations and will continue to monitor the progress the operator takes in addressing these.

“When a missed item has the potential to affect the safety of a flight, a secondary means of assuring the item has been removed should be employed,” Mr Mitchell concluded.

“Similar to procedures employed for other covers on aircraft, a means to account for what equipment has been removed from the aircraft before being stowed or retained by ground agents will provide the crew with another opportunity to detect when a bung or cover has not been removed.”

Read the final report: Aircraft preparation event involving Saab 340B, VH-ZLJ, Cairns, Queensland on 16 November 2022

Publication Date 26/10/2023

WTD?? 

There is some bizarre disconnections with this whole (IMO) WOFTAM investigation. To begin here is the entry for the investigation from my 22 March post at the top of the page:  42. AO-2022-058 (Short)

So for at least 4 months this investigation was listed as a 'Short' investigation:

Short investigations

Short investigations provide a summary and analysis of commonly occurring transport safety accidents and incidents. Investigation activity includes sourcing imagery and documentation of any transport vehicle damage and/or accident site, conducting interviews with involved parties, and the collection of documents such as procedures and internal investigations by manufacturers and operators.

Short investigation reports include a description of the sequence of events, limited contextual factual information, a short analysis, and findings. Findings include safety factors (the events and conditions that increased the risk of incident or accident happening) but only examine the actions and conditions directly relating to the occurrence and any proactive safety actions taken.

IMO, with no injuries, fatalities or even damage to the aircraft,  even a short for this operational occurrence was overkill. If anything perhaps the issuing of an OB..

Occurrence briefs

Occurrence briefs provide the opportunity to share important safety messaging and information with industry and the public in the absence of an investigation. They are a short factual summary to detail the circumstances surrounding an occurrence, which only uses information gathered during the initial notification, and from any follow-up information with relevant parties.

Because occurrence briefs are not investigations under the Transport Safety Investigation Act 2003, the information within them is de-identified. While they do not include any analysis, findings, safety issues, safety actions or recommendations, occurrence briefs do provide an additional opportunity to learn from the experiences of others.

Occurrence briefs can be produced by ATSB Transport Safety Investigators or members of our Safety Reporting Team (all of whom have significant transport industry experience).

...with the operator's consent and after reviewing the REX SMS investigation report and findings.

However sometime after the 22nd of March a decision was made to escalate the investigation to 'defined':

Defined investigations

Defined investigations look at transport safety accidents and incidents of a more complex nature than short investigations, and seek to identify systematic safety issues that reveal underlying causes of an occurrence. They involve several ATSB resources and may involve in-the-field activity or be an office-based investigation. Evidence collected can include recorded flight and event information, multiple interviews, analysis of similar occurrences, and a review of procedures and other risk controls related to the occurrence.

Defined investigation reports include an expanded analysis to support the broader set of findings within the report and may include safety factors not relating directly to the occurrence. Defined investigations may also identify safety issues (safety factors with an ongoing risk) relating to ineffective or missing risk controls. The report also identifies safety issues, along with proactive safety action taken by industry and ATSB safety recommendations.

 

 Perhaps the key here is the last line in bold? However that would suggest that the identified safety issues were only discovered at least some four months into the investigation, after 1st interviewing the flight crew and reviewing the operator/SMS actions/inactions etc.

Safety Issues

AO-2022-058-SI-01
No procedure for storage and accountability

AO-2022-058-SI-02
Horizontal stabiliser bung design considerations

This brings me to the next aberrations with this bizarre investigation report. After reading through the FR there doesn't appear to be one reference to the REX SMS, instead we get this blurb about safety risk mitigation:

Risk assessment

While a risk assessment of the bird nesting hazard led to the implementation of the procedure to install the horizontal stabiliser bungs, the operator did not conduct a separate risk analysis of the potential hazard a control surface bung could induce. Although the design incorporated features to aid in the recognition of the bungs when they were installed correctly, the evidence indicated that the design allowed for an incorrectly installed bung or one not displaying as designed to go undetected.

Existing procedural checks designed to detect fouled or jammed controls did not identify the incorrectly installed bung and there was no documented consideration given to assuring that a bung would be ejected prior to take-off, after which time it could have had the potential to adversely affect the safety of a flight.

And this totally inappropriate opinion piece under the summary of 'what has been done as a result'

The operator has commenced a risk assessment to formalise the procedures around the use of the horizontal stabiliser bungs. To support this, an engineering order was obtained to document and approve the manufacture of the bungs.

However, these actions did not address the issues around the storage and accountability of the bungs when they are removed or the aspects around the identification of an installed bung or the safe operation of the aircraft if the bungs were not removed. As such, the ATSB issued two safety recommendations and will continue to monitor the safety issues and provide website updates.

Such risk assessments are (or should be) the primary function of the REX SMS? If this occurrence has not been effectively addressed (in an appropriate time) by the REX SMS, then I would suggest that is the real latent significant safety issue that should have been identified by Popinjay's crew...

The last point I would make is that those SRs were only issued to the operator yesterday:

Date issue released 26/10/2023

Safety Issue Description

There were no formal procedures for the storage and accountability of horizontal stabiliser bungs after they were removed from the aircraft.

---

Date issue released 26/10/2023

Safety Issue Description

The design of the horizontal stabiliser bungs did not consider aspects that would ensure the identification of an installed bung, or the safe operation of the aircraft if the bungs were not removed prior to flight.

WTD? 

MTF...P2 

[P7_TOM]

This is how a 'true professional' with an understanding of what its all about sets about getting 'the job' done – properly.

- HERE – courtesy Sky News../ Thanks..

Update:

[Peetwo]

Proof of Popinjay obfuscation of Safety Issues and Recommendations - WTD??

Courtesy of the NTSB:

Safety Recommendations

The NTSB issues safety recommendations to address specific safety concerns uncovered during investigations and to specify actions to help prevent similar accidents from occurring in the future. Safety recommendations are our most important product because they alert government, industry, and the public to the critical changes that are needed to prevent transportation accidents and crashes, reduce injuries, and save lives.

We:

• issue recommendations to the organizations best able to take corrective action, such as the US DOT and its modal administrations, the Coast Guard, other federal and state agencies, manufacturers, operators, labor unions, and industry and trade organizations.
  
• issue safety recommendations at any point during the investigation of transportation accidents and in connection with safety studies.
  
• monitor the progress of action to implement each recommendation until it is closed, which usually takes several years.
  

Courtesy the TSBC:

Recommendations

As part of its mandate, the TSB makes recommendations to eliminate or reduce safety deficiencies that pose significant risks to the transportation system and warrant the attention of regulators and industry.

Under the Canadian Transportation Accident Investigation and Safety Board Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies. The Act does not require other stakeholders to respond to the TSB's recommendations, but they usually do.

Using the Assessment rating guide, the Board assesses responses to recommendations according to the extent to which the safety deficiency has been or is being addressed. Once the responses have been assessed as Fully Satisfactory, the recommendations are closed. The TSB continually monitors the progress being made on its recommendations.

---

Air transportation safety letters and concerns

Safety concerns

Safety concerns provide a marker to the industry and the regulator that the Board has identified a safety deficiency for which it does not yet have sufficient information to make a recommendation. As more data and analysis become available, and if the safety deficiency is found to be systemic and not redressed, the safety concern may lead to a recommendation. Safety concerns are usually communicated in final investigation reports.

Safety information letters

The TSB sends safety information letters to regulatory and/or industry stakeholders to advise them of potentially unsafe acts or conditions identified during an investigation that pose low risks and do not require immediate remedial action. The letters aim to promote safety or clarify issues that a stakeholder is already examining, and are sent before the investigation has been completed. Those that do not contain privileged or proprietary information are posted here.

Safety advisory letters

Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and are used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety.

Spot the difference?? Via Popinjay HQ:

Safety issue: a safety factor that:

a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and
b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operational environment at a specific point in time.

Safety action: the steps taken or proposed to be taken by a person, organisation or agency in response to a safety issue.

Safety recommendation: a formal safety recommendation made either during or at the end of an investigation, where the ATSB remains concerned that a safety issue has yet to be adequately addressed by the relevant organisation.

Remember that in the course of the infamous 1st ATSB PelAir ditching investigation (and the subsequent Senate AAI Inquiry Report - now dead, buried and cremated), beyond all sensible Reason it was discovered that the ATSB initially identified a 'critical safety issue' that after much pushback from CASA was eventually downgraded to a minor safety issue...

From PAIN Supplementary submission: https://auntypru.com/wp-content/uploads/...lement.pdf



Since that time 'critical safety issues' still get a passing mention in all investigation updates, prelim, interim reports and even in Popinjay's bollocks non-interactive media releases.

Via Mornington Peninsula News:

“A final report will be released at the conclusion of the investigation, but if we identify a critical safety issue during the course of the investigation, we will immediately notify relevant parties so appropriate and timely safety action can be taken.”

The ATSB used to have definitions for the different safety issue categories but apparently no longer. So who is it that now defines whether a safety issue is in fact critical?

Trying to join the dots, I referred to the ATSB Aviation 'safety issues and actions' database webpages. This only led to further bemusement because according to that page (which I presume is in chronological order?) the last entry date for a safety issue is for 26/10/2023. However we all know there has been numerous safety issues issued in association with several investigation reports since.

In particular the following, which ended up with Popinjay issuing a SR to CASA: (Reference:  Popinjay v Su_Spence; closing safety loops?? - Let's do the timewarp again!)

ATSB Response

Throughout the course of this investigation, the ATSB found numerous optional VFR into IMC risk controls available to the operator that were not mandated for their day VFR pilots. This was explained in the safety analysis and has extended to the operator’s responses to the safety issues, citing the provision of training outside the regulatory requirements as impractical and uncommercial. Performance-based approaches to safety should complement prescriptive approaches and not replace them as it can lead to the treatment of safety requirements as ‘optional’ and may result in competitive advantages to operators with lower safety standards. Performance-based approaches should also be responsive to outcomes, such as accidents, so that safety requirements can be adjusted to meet the acceptable level of safety.

While equipment, systems and training will greatly improve the chances of recovering from a VFR into IMC event, this is not the extent of the ATSB’s report, which has also discussed operational information, organisational information, research studies of VFR into IMC and intervention strategies, including avoidance and recovery. The ATSB report also acknowledges the cost of the autopilot system for the EC130 helicopter and the helicopter industry's opposition to basic instrument flying training, which was a majority but not a consensus.

The ATSB acknowledges the work done by CASA to develop and deliver flight planning and weather assessment educational material, safety seminars and guidance material, which included the ‘Don’t push it, land it | Flight Safety Australia’ campaign for helicopter pilots to make the decision to land when confronted with deteriorating weather. However, the ‘Don’t push it, land it’ strategy is only applicable to helicopters operating underneath the cloud base and is not applicable to ‘VFR over the top’. In this accident, the pilots proceeded ‘VFR over the top’ before the VFR into IMC event.

The Australian National Aviation Safety Plan 2021-2023, to which the ATSB and CASA were contributing agencies, stated Australia’s acceptable level of safety performance included:

Quote:No accidents involving commercial air transport that result in serious injuries or fatalities, no serious injuries or fatalities to third parties as a result of aviation activities and improving safety performance across all sectors.Therefore, any risk assessment of a fatal commercial air transport accident by CASA should be consistent with Australia’s stated acceptable level of safety performance. To progress towards this level of safety, CASA need to capture lessons learned from fatal accidents in Australia in the Australian aviation standards.

In addition to this accident, the ATSB has recently investigated a fatal VFR into IMC accident in Tasmania, AO-2018-078, by a commercial aeroplane pilot en route to collect passengers, a fatal VFR into IMC Part 135 (Australian Air Transport Operations—smaller aeroplanes) accident in Queensland, AO-2022-041, and is currently investigating a fatal Part 135 accident involving adverse weather in the Northern Territory, AO-2022-067. As CASA has not committed to taking safety action in response to this safety issue, the ATSB is issuing a safety recommendation.

In addition to that SI/SR there was four others issued: 

 AO-2022-016-SI-01 - Operator proficiency check requirements

AO-2022-016-SI-02 - Inadvertent instrument meteorological conditions recovery procedure and training


AO-2022-016-SI-03 - Pre-flight risk assessment

AO-2022-016-SI-04 - Risk management of inadvertent instrument meteorological conditions

It is interesting to note that none of those SIs, including the SR, have an issue date. In fact I believe that no safety issues published in any aviation investigation final report, since 26/10/23??

However there is some chronological evidence of when the above safety issues were at least acknowledged and began to be actioned by the addressees:

Action description[b]

On [b]6 April 2023, Microflite advised the ATSB that they had reviewed their operator proficiency check for their day visual flight rules (VFR) pilots and added knowledge and practical skills checks for avoiding and recovering from inadvertent entry into instrument meteorological conditions (IMC).

On 21 November 2023, Microflite advised the ATSB that:

Microflite does not intend to mandate training for inadvertent entry into IMC for all Day VFR Pilots in unstabilised single-engine VFR helicopters. While the potential benefits of such a policy are understood, introducing this requirement for all pilots is impractical and uncommercial, as:

a. such training is not required by the current regulations;
b. the perishable nature of this training means that one-off licencing/training is insufficient – annual training and regular competency checks are required; and
c. there is an insufficient number of instrument-rated instructors and aircraft available to service the single-engine Day VFR environment.

Microflite will (in excess of its regulatory obligations) implement such training where appropriate and will continue to emphasise ICARUS device training and improved decision making for pilots (including non-IFR pilots) who operate these aircraft.

---

On 21 November 2023, the Civil Aviation Safety Authority advised the ATSB that:

This safety issue is misconceived as it does not consider the safety management potential of the combined air transport regulatory suite.

It also relies, as does the report, entirely on the context of needing to add either additional equipment (instrumentation), additional systems (SAS, autopilots) and additional flight crew training (instrument flight training) and flight crew recency (IF recency), as the solution to IIMC events.

Whilst these may offer some assistance, they are in most instances reactive, after IIMC has occurred, and are expensive fixes, which notably, the industry has already rejected.

CASA recommends the safety issue is withdrawn for the reasons outlined in this overall feedback and substituted with an action to include further guidance material on IIMC within the AMC/GM for Part 133 of CASR. As is the case with EASA and transport Canada, noting transport Canada’s material is primarily associated with “white out condition IIMC” which is a very rare event in Australia.

CASA also notes the numerous articles it has already published on VFR into IMC in its Flight Safety magazine on this issue.

Hmm...much more to follow me thinks?? 

P2