[Peetwo]

AOPA Oz tolls the bell on the independent statutory safety investigator the ATSB!! - 

Excellent observations and critique from Clinton McKenzie, on the hypocrisy, mismanagement and total unfit for purpose of the current Popinjay version of the ATSB (last night on the AOPA live session, from 44 minutes):

The following is the video Estimates segment, Hansard and current SoE to which CM refers:

More ATSB (Popinjay) WOFTAM reporting vs NTSB benchmark as World No.1 in TSI??

Meanwhile, at the recent Estimates hearing, Popinjay begged limited resources and the Ministerial SoE as reasons why the ATSB did not investigate the Kybong mid-air collision:

Senator McKENZIE: Recreational Aviation Australia recently declined to investigate a fatal accident in Kybong, Queensland due to the burden these investigations were putting on the organisation. Has the bureau had any discussions with Recreational Aviation Australia about their resourcing concerns?

Mr Mitchell : I've certainly had discussions with RAAus over that particular incident and others. There have been a number of incidents. I think, in that particular sector: there are anywhere between six to 10 fatal accidents, generally, per year. The recent decision by RAAus not to investigate there is certainly one for them. In terms of our priority list, our priorities lie with general greatest benefit for the travelling public, and sport, recreational and experimental aircraft are lower down on our list.

Senator McKENZIE: That significant service is now no longer to support police and coroners into the future. Recognising the resourcing concerns, have you asked the minister for more resources in the upcoming budget round?

Mr Mitchell : We are certainly in discussions with the department around our resourcing and expectations. Our expectations need to be matched with resourcing, so it has been a long established position that we do not investigate in that recreational space, and that has been since 2014, since the Forsyth review was conducted.

Senator McKENZIE: So the minister would actually have to change the expectations for you to actually do that—is that your argument here?

Mr Mitchell : I think it would be a combination of changing expectations or funding and potentially—

Senator McKENZIE: Let's hope the minister funds you appropriately so you can assist Recreational Aviation Australia with their coronial assistance. And my apologies we couldn't spend more time, but I'll have questions on notice. Thank you, Mr Mitchell.

Talk about 'discontinuity' -   

---

SoE ref: https://www.atsb.gov.au/about_atsb/minis...pectations

2. Governance

I expect that the Chief Commissioner and Commissioners will continue to work to enable the effective operation of the ATSB as the national transport safety investigator in accordance with the Act.

I expect that in performing its functions, the ATSB will provide timely advice to Government when the costs of necessary investigation activities are likely to exceed established ATSB budget levels, so that consideration can be given to the need for budget supplementation.

I expect that the Chief Commissioner will keep the Secretary of the Department of Infrastructure, Transport, Regional Development and Communications (Department) and myself informed of the ATSB's actions in relation to the requirements stated in this SOE and promptly advise about any events or issues that may impact on the operations of the ATSB, including through the provision of timely quarterly progress reports against the Corporate Plan and this SOE.

I expect the ATSB to perform its functions consistent with Australia's international obligations where appropriate, including the requirements of the International Civil Aviation Organization.

I also expect the ATSB to implement any recommendations of the Australian National Audit Office and continue to work towards the timely finalisation of investigations to support continuous improvement in transport safety.

MTF...P2 

[Peetwo]

The current clusterduck that is the ATSB - where it all began?? -

IMHO the total dysfunctionality that is our current National Transport Safety Investigator, harks back to when Albo legislated the ATSB as an independent statutory authority.

Courtesy the 'Outline' of the TRANSPORT SAFETY INVESTIGATION LEGISLATION AMENDMENT BILL 2009:

The Transport Safety Investigation Amendment Bill 2009 (the Bill) will amend the Transport Safety Investigation Act 2003 (TSI Act) to establish the Australian Transport Safety Bureau (ATSB) as a Statutory Agency within the meaning of the Public Service Act 1999 (PS Act).  The Agency will be established with a Commission structure and come into being on 1 July 2009.

In 2007 Mr Russell Miller AM was tasked by the then Government to review the relationship between the Civil Aviation Safety Authority (CASA) and the ATSB.  In finding there was room for improvement in the way the agencies interact, Mr Miller addressed the ATSB’s governance structure.  Mr Miller recommended that the Australian Government move to clarify the ATSB’s independence as the national safety investigation agency.  The Australian Government accepted this key recommendation, which received strong support from industry, and addressed it in the National Aviation Policy Green Paper (2 December 2008).

Investigations that are independent of the parties involved in an accident, transport regulators and government policy makers, are better positioned to avoid conflicts of interest and external interference.  Independence for the accident investigation authority is consistent with international standards.  Standard 5.4 of Annex 13 to the International Convention on Civil Aviation (the Chicago Convention) states:

The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct.

Enhanced independence for the ATSB results from a combination of factors.  The position of the Executive Director of Transport Safety Investigation, appointed by the Secretary of the Department, will no longer exist.  Instead, Commissioners appointed by the Minister, consisting of the Chief Commissioner and two part-time Commissioners (with the power to appoint more) will be responsible for administering the functions of the TSI Act and exercising its investigation powers.  The Minister will have the power to provide notice of his or her views on the strategic direction for the ATSB, to which the ATSB must have regard.  However, other than the ability for the Minister to require the ATSB to investigate a particular matter, the ATSB will not be subject to a direction from anyone with respect to the exercise of its powers and performance of its functions.

The creation of a statutory agency will also give the ATSB responsibilities in its own right under the PS Act and the Financial Management and Accountability Act 1997 and discretion with respect to the management of its staff and resources consistent with these Acts.  The ATSB will, therefore, have operational independence with respect to the exercise of its investigation powers and functional independence with respect to the administration of its resources.

"..and addressed it in the National Aviation Policy Green Paper (2 December 2008)..."

These were the segments from the 'Green Paper' referred to (above):

 

"...In 2007 Mr Russell Miller AM was tasked by the then Government to review the relationship
between CASA and the ATSB. Mr Miller’s work arose from a recommendation of the Queensland
Coroner following his inquiry into the fatal accident at Lockhart River in 2005.

The Government released Mr Miller’s report for public comment in March 2008 (it can be accessed
at <http://www.infrastructure.gov.au/aviation/safety/atsb_casa_report.aspx>).

In finding there was room for improvement in the way the agencies interact, Mr Miller addressed the
ATSB’s governance structure and the issue of protection of safety related information. With regard
to governance, Mr Miller recommended that the Government move to clarify the ATSB’s
independence as the national safety investigation agency. The Government accepts this key
recommendation, which received strong support from industry, and will implement it through the
necessary legislative and administrative changes.

The Government’s response to aviation sector changes needs to go beyond the governance
changes. We need to ensure that Australia’s key safety agencies – CASA and the ATSB – have
the necessary resources to meet their responsibilities...

...Safety agency governance: independence for the ATSB

The Government has decided to establish the ATSB as a statutory agency and to introduce a
Commission structure to enhance its independence. Responses to the Miller review revealed
strong industry support for an independent ATSB and an alternative governance model was one of
the review’s recommendations.

The Commission structure for the ATSB will comprise a full time Chair, who will also be the Chief
Executive, two part-time commissioners and provision for additional commissioners to be appointed
for particular investigations as necessary. The Commission will be appointed by and report to the
Minister and the new agency will be established under the FMA Act and the Public Service Act
1999.

The Executive Director of Transport Safety Investigation’s current powers under the TSI Act will be
transferred to the Commission, which would have powers to delegate to appropriate levels in the
ATSB. The ATSB Chief Executive will be responsible for the day-to-day conduct of accident and
incident investigation under delegation from the Commission as a whole.

A Commission structure will support the ATSB’s enhanced independent status. The Commission
will provide guidance on the selection of accidents and serious incidents to be investigated. It will
also support the ATSB in encouraging safety action ahead of final reports, which will reduce the
need for safety recommendations and ensure that any safety recommendations deemed necessary
are in a format that will best contribute to practical safety improvements. The Commissioners will
be appointed with an appropriate mix of skills and expertise.

The Commission will establish a framework for the conduct of the ATSB’s work and delegation of
the investigative functions to staff as appropriate, with the expectation that at least one
commissioner would be involved in the sign-off of each report and that multiple commissioners
would consider the most sensitive reports.

A Commission will help to facilitate interaction with industry and other agencies and improve quality
control. It would oversee and approve ATSB reports and ensure investigation reports are
communicated effectively to industry and the safety regulator, CASA, and acted upon as a key par of Australia’s aviation safety system.

Legislative amendments to the TSI Act to give effect to the governance changes are to be
introduced in early 2009, with the new Commission to be in place by 1 July 2009.

Agency cooperation

The Miller review included some other recommendations to ensure appropriate coordination and
cooperation between the ATSB and CASA, including a range of operational matters that are
already being addressed by the agencies. The Government expects that the creation of a Board
for CASA and a Commission for the ATSB will help build cooperation across agencies.

The Miller review also suggested amendments to the provisions relating to the sharing of evidence
obtained in an investigation with CASA as the regulator. These recommendations raised serious
sensitivities in the industry, with a significant number of key industry players indicating their concern that a change in the current balance on information sharing could prejudice the industry’s level of cooperation with investigators.

The current provisions of the TSI Act offer only limited scope for sharing information for safety
purposes. There is room for further dialogue between the agencies about how those provisions are
used. Australia is not alone in grappling with this issue and discussions on a refined framework are
proceeding within ICAO.

The Government does not propose to initiate legislative change on these issues at this stage, but
will look to the agencies to work together towards agreement on an approach based on the current
provisions. The Government will also consider options for introducing a tiered system of voluntary
and mandatory reporting of safety issues to CASA that will allow CASA to take appropriate safety
action.

Following up safety recommendations

Consistent with recent ICAO decisions, the Government intends to introduce legislative
amendments that will require written responses to ATSB safety recommendations within 90 days.

The revised governance arrangements for CASA and the ATSB will also allow for a better outcome
from the ATSB’s findings and safety recommendations, which will be subject to review and
consultation with regular reports to the Minister. This process will provide confidence that ATSB
safety issues are being addressed and implemented and ensure feedback to the ATSB so that it
can best target future recommendations to achieving practical safety outcomes.

Agency funding

The Government will ensure that Australia’s aviation safety agencies are appropriately funded to
enable them to perform their functions. The Government will consider CASA’s long-term funding
needs, which were last reviewed in the 2005-06 Budget. CASA’s funding base comprises a mix of
budget appropriation, revenue from aviation fuel excise and cost recovery of regulatory service
fees. Consideration of CASA’s overall funding will include resourcing of the Office of Airspace
Regulation to ensure the continued development of that important regulatory role. To ensure the
costs of CASA’s safety regulation do not place an excessive burden on the regional and general
aviation industries, options will be considered for limiting CASA’s regulatory service fees to that part
of the industry.

The Government will also consider funding to support the new governance arrangements for CASA
and the ATSB, and the ATSB’s new statutory independence. Consideration will also be given to
the ATSB’s funding base to ensure it is appropriately resourced to discharge its important
investigatory role..."

Somewhat ironically the first real test case for a high profile investigation conducted under the new 'Commission' system of ATSB Governance was to be the PelAir Norfolk Island ditching investigation and we all know how that ended up...  

Consequently the July 2009 amendment brought us the deeply flawed character (with absolutely NFI about transport safety investigation) Beaker followed by a severely narcissistic individual (with absolutely NFI about transport safety investigation) HVH, who had the mendacity to threaten his own senior investigative officers with criminal sanctions if they were to talk out of school about the search for MH370. To finally Popinjay (again with absolutely NFI about transport safety investigation) who apparently believes that both the 2014 Forsyth report and the current Ministerial SoE directs him to ignore the very real safety issues of two recreational aircraft having a midair collision in busy airspace, that includes high capacity RPT aircraft - WTF??   

So a simple 14 year review of the effectiveness of the 2009 'Commission' amendment to achieve the aims of the 2008 'Green Paper' should include the findings of:

1) ..the Senate AAI inquiry: https://www.aph.gov.au/Parliamentary_Bus...port/index

2) ...the Forsyth review: https://www.infrastructure.gov.au/sites/...sponse.pdf 

3) ...the findings of the TSBC peer review: https://www.bst-tsb.gc.ca/eng/coll/2014/...41201.html plus ProAviation review: http://proaviation.com.au/2014/12/03/can...#more-2464 

4) ...the 2017 ICAO audit: https://www.infrastructure.gov.au/sites/...t_full.pdf

5) ...the 14 March 2019 ANAO ATSB audit report: https://www.anao.gov.au/work/performance...ccurrences

In particular how is this 'agreed to' recommendation working out?

Recommendation no.1

Paragraph 2.8

The ATSB implement strategies that address the decline in the timely completion of short investigations.

Australian Transport Safety Bureau response: Agreed.

              
Reflect on this in regards to the above: Proof of ATSB delays and ICAO Annex 13 non-compliance?? 

 
  MTF...P2 - 

[Peetwo]

The current clusterduck that is the ATSB: Part II

One of the other spin-offs of Albo's 2009 amendment to the TSI Act was that the strategic direction of the ATSB is now documented in the ATSB Corporate Plan and in the 'Entity resources and planned performance' budgetary statement: https://www.infrastructure.gov.au/sites/...9_ATSB.pdf
 

 1.1 Strategic direction statement

The Australian Transport Safety Bureau (ATSB) is an independent statutory agency of the Australian Government conducting safety investigations in the aviation, rail and interstate and overseas shipping modes of transport. It is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers.

The ATSB’s purpose is defined by its mission statement:

• Improve transport safety for the greatest public benefit through our independent investigations and influencing safety action.

In reference to the public benefit:

• The ATSB focusses on the public interest where the safety of passengers and workers on an aircraft, train or ship is concerned. The ATSB focusses on the public interest when it comes to the significant costs that can result from an accident, particularly where there is significant damage to public infrastructure or an impact on the national economy.

The Transport Safety Investigation Act 2003 (TSI Act) makes it clear that, in carrying out its purpose, the ATSB cannot apportion blame, assist in determining liability or, as a general rule, assist in court proceedings.

Through independent investigations, the ATSB seeks to identify safety issues for action by organisations with responsibility for managing risk. The ATSB’s approach to identifying safety issues encompasses targeting safety improvements for the greatest public benefit. The safety issues the ATSB identifies are characteristic of an organisation or a system rather than a characteristic of a specific individual. The ATSB directs its resources to investigations that have the broadest safety effect on transport systems.

The ATSB does not have powers to force operators, manufacturers and regulators to take action. The ATSB relies on its ability to influence. An influencer uses their authority, knowledge, position and relationship to shape the decisions of others. The ATSB builds relationships with others to support safety action. The ATSB has stakeholders willing to be advocates for safety messaging. Where the ATSB is concerned that not enough is being done in response to safety issues being raised, the ATSB will work to campaign for action that prevents accidents.

The ATSB does not have the resources to investigate every accident and incident that occurs in the aviation, rail and marine sectors each year. In order to provide assurance that the ATSB’s finite resources are being used for the greatest safety benefit, the ATSB will continue to work with government and industry stakeholders to clarify the priorities for its existing jurisdiction and the potential for its expansion. For rail investigations, the ATSB relies on the resources provided by the states and territories through agreements.

The ATSB maintains a national information set of all safety-related occurrences in aviation and of all accidents and significant safety occurrences in rail and the interstate and overseas marine sectors. The information it holds is essential to its capacity to analyse broad safety trends and inform its investigation and safety education work, as well as constituting an important public information resource. The ATSB is enhancing its capacity for a data driven approach to the performance of its investigation, research, communication and education functions.

The ATSB is committed to close engagement with its international counterpart agencies and relevant multilateral organisations. The ATSB places a specific emphasis on engagement with countries in the Asia–Pacific region, particularly with Indonesia and Papua New Guinea.

The ATSB invests in studying and contributing to the methodologies and techniques used by accident investigation authorities in transport and non-transport modes across the world. The ATSB does this by employing academic discipline, supported by our partnership with the Royal Melbourne Institute of Technology (RMIT) University. The ATSB’s partnership with RMIT to deliver transport safety investigation qualifications commits the ATSB to investing in the training and skill development of people in a position to support improvements to transport safety.

Detailed information about the ATSB's purpose, operating context, activities and performance measures is published in the ATSB Corporate Plan available at: https://www.atsb.gov.au/media/5780101/at...021-22.pdf. 

And from the current corporate plan we (apparently) get a real insight of Popinjay's interpretation of the current strategic direction of the ATSB...

Ref: https://www.atsb.gov.au/sites/default/fi...022-23.pdf

INTRODUCTION



I am pleased to present the Australian Transport Safety Bureau’s (ATSB) Corporate Plan, which covers the period 2022-23 to 2025-26.

This Corporate Plan has been prepared consistent with paragraph 35(1)(b) of the Public Governance, Performance and Accountability Act 2013 and the relevant provisions of the Transport Safety Investigation Act 2003 (the TSI Act), which establishes the ATSB. The Corporate Plan is also consistent with the Minister’s revised Statement of Expectations 2021–23 (SOE) for the ATSB, as notified under Section 12AE of the TSI Act. The SOE sets out clear expectations that the ATSB’s resources be used in an efficient, effective, economical and ethical way, following best practice principles and guidelines.

I acknowledge this continues to be a time of great uncertainty for the transport industry in general, and aviation in particular. As an independent safety agency, the ATSB is continuing to apply our safety knowledge and expertise and carefully monitoring the return to safe and reliable transport operations. As an operational agency, the ATSB continues to deploy accident investigation teams where and when necessary during this pandemic.

I look forward to working with the newly elected Federal Government, to ensure the Bureau is well positioned to meet the Minister for Infrastructure, Transport, Regional Development and Local Government’s expectations for the ATSB’s role in improving transport safety. I acknowledge the ongoing uncertainty for Australia’s transport industries operating in an evolving COVID-normal environment and the challenging economic conditions that these sectors face. I am also mindful that such challenges will need to be internally managed to ensure the ATSB maintains its ability to undertake and meet prescribed functions and key deliverables.

I have been the ATSB’s Chief Commissioner for 12 months now. I am aware of the calls stemming from a number of inquiries and associated reports, seeking to extend the ATSB’s services through an expanded remit. The ATSB will provide input into those inquiries as required. However, any decisions to change the ATSB’s remit are a matter for Government. It is my immediate priority to address the ATSB’s existing budgetary challenges – specifically the shortfalls in rail investigation resources resulting from unsustainable funding arrangements outside our core appropriations.

In my time as Chief Commissioner the ATSB has demonstrated itself to me as a highly capable organisation. In the past 12 months we have released a number of complex and industry significant reports that carry wide-ranging safety implications to the relevant transport modes; one such report is the ATSB’s investigation into the mid-air collision near Mangalore Airport in Victoria in 2020. The investigation highlighted the importance of air traffic hazard assessment and the value of aircraft owners installing Automatic Dependent Surveillance-Broadcast (ADS-B) devices to assist pilots with the identification and avoidance of conflicting traffic. Other significant investigations include an investigation into a level crossing accident north-east of Kalgoorlie in Western Australia in 2021 highlighted the risks of driver distraction and the consequences when heavy vehicles and trains operate in the same geographical space and, an investigation into a collision between a bulk carrier and a fishing vessel off the entrance to Port Adelaide in South Australia in 2020 highlighted the need for crew to keep a lookout by all available means including use of radar, radio and automatic identification systems. 

As a relatively small operationally-focused agency, the ATSB will need to anticipate change and adapt to ensure we are meeting the needs of government, industry, and the traveling public. Accordingly, I have been working with staff from across the agency to develop a strategic plan that clearly identifies the key objectives, strategies and actions to be given priority over the short to medium term. The plan, to be released this financial year, will have a focus on:

• enhancing our products and stakeholder engagement for improving transport safety
  
• fostering organisational resilience 
  
• affirming our role as the national transport safety investigator.
  

An example of the immediate action we are taking, is the greater utilisation of audio-visual content which will increase consumption of our investigation reports and advance important safety messaging. Stakeholders can also expect the ATSB to produce more statistical and research-based outputs ensuring we are making the best use of available data and the specialist capabilities of our people. We will balance these actions with our core occurrence investigation activities which must continue to be managed within our demand/capacity limitations as this will enable us to expedite production and publishing timeframes.

The strategic plan will position the ATSB to be able to provide greater value for persons and organisations seeking to use our products to take safety action.

Based on my recent interactions with a range of prominent overseas safety investigation bodies, it is evident the ATSB is considered a highly reputable agency and world leading. As Chief Commissioner, I am fully committed to continuing to work innovatively and collaboratively with all relevant stakeholders to enhance and amplify our contribution to improving transport safety both domestically and internationally.

The ATSB continues to work towards achieving its new performance measures established in the 2020-21 Corporate Plan. Through revised performance criteria, we are focused on improving our timeliness, demonstrating safety action taken in response to our investigations, ensuring our findings are defendable, and using our resources efficiently and effectively.

Angus Mitchell
Chief Commissioner and CEO

---

"..continues to work towards achieving its new performance measures established in the 2020-21 Corporate Plan..."

Refer to pages 12 to 14 here: https://www.atsb.gov.au/sites/default/fi...020-21.pdf

Where to start with all these bollocks statements? - How about pg 11 (241) of the ATSB budgetary statement at KPI5:

KPI 5 – Median time to complete
investigations:
• Short investigations - 7 months
• Defined investigations - 14 months
• Systemic investigations - 20 months

---

Tracking towards 7 months
Tracking towards 14 months
Tracking towards 20 month

'Tracking'?? - Err really: Proof of ATSB delays and ICAO Annex 13 non-compliance??

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)

Is there anyone who is actually going to hold Popinjay to account on reneging on honouring many of these so called non-performance indicators?? - 


MTF? - Yes much!..P2 

[Sandy Reith]

“ Is there anyone who is actually going to hold Popinjay to account on reneging on honouring many of these so called non-performance indicators?? -  Dodgy “

Good question, action required but we are stuck with the quaint notion that whole of the ATSB body should be completely independent. Of course the investigations should be unbiased and not subject to outside influence. Accident investigation, like justice, should be impartial and seen to be impartial. Unfortunately the Canberra revolving door bureaucracy has an element of “all in together this fine weather.”

It’s no accident that according to the ABS the inhabitants of Canberra and Queanbeyan live on incomes 40% higher than the rest of us.

No Government instrumentality should be immune from some level of Parliamentary control of its overall performance.
The rush away from Departmental control (the Westminster tradition of responsible government) once again proving to be a mistake.

[Peetwo]

PPR (Popinjay Performance Review): One from the list - 26. AO-2022-033 (Short)??

Ref:

The current clusterduck that is the ATSB: Part II

"..continues to work towards achieving its new performance measures established in the 2020-21 Corporate Plan..."

Refer to pages 12 to 14 here: https://www.atsb.gov.au/sites/default/fi...020-21.pdf

Where to start with all these bollocks statements? - How about pg 11 (241) of the ATSB budgetary statement at KPI5:

KPI 5 – Median time to complete
investigations:
• Short investigations - 7 months
• Defined investigations - 14 months
• Systemic investigations - 20 months

---

Tracking towards 7 months
Tracking towards 14 months
Tracking towards 20 month

'Tracking'?? - Err really: Proof of ATSB delays and ICAO Annex 13 non-compliance??

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)

Is there anyone who is actually going to hold Popinjay to account on reneging on honouring many of these so called non-performance indicators?? - 

The Popinjay definition of 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.

Surprise...surprise we actually have an example of a short investigation from the list above that has actually been completed -  : AO-2022-033

This non-event was strangely considered to have significant enough safety value to be accompanied by one of those bollocks media blurbs by this week's Director of Transport Safety Kerri Hughes...  

Contaminated pitot tubes before 737 freighter’s unreliable airspeed indications



Key points

• 737 freighter returned to Perth after flight crew observed discrepancy between altitude and airspeed on the pilot and co-pilot’s indicators.
  
• Investigation found that covers on the aircraft’s pitot-static probes had melted during maintenance.
  
• Although the probes were cleaned, residue was found on probes after flight.
  
• Incident highlights importance of maintaining high level of attention to damage and contamination when working on and inspecting these components.
  

The flight crew of a 737 freighter were presented with unreliable flight data information two days after the aircraft’s pitot probes were contaminated during maintenance, an ATSB investigation details.

The Airwork-operated Boeing 737 freighter, with four crew on board had departed Perth on 10 June 2022 for a freight service to Christmas Island, via Port Hedland.

As the aircraft was levelling off at 33,000 ft, the flight crew observed a 340 ft discrepancy between the altitude displayed on the captain’s altimeter, and the altitude on the first officer’s altimeter, which was connected to the autopilot.

The flight crew also observed discrepancies between airspeed and Mach numbers.

After descending to 30,000 ft and working through the relevant quick reference handbook, the flight crew established the first officer’s indications were reliable, and advised air traffic control of a need to return to Perth.

After an uneventful landing in Perth, ground crews found foreign residue adhered to the lower surfaces of all four of the aircraft’s pitot-static probes.

“The ATSB established that, during an engine ground run 2 days prior to the incident, the pitot‑static probe covers were not removed, and the automatic pitot heat was not isolated as required by the ground run procedures checklist,” said ATSB Director Transport Safety Kerri Hughes.

“As a result, the covers melted onto the probes. Although cleaned, residue remained on the probe surfaces, which had the potential to compromise the accuracy of the pitot-static instruments in-flight.”

However, as seven flights had been completed between the ground run and the incident flight with no altitude discrepancies reported during this time, the ATSB was unable to a establish a link between the remaining residue and the flight.

Irrespective, pitot probes are extremely sensitive to damage and disruption.

“Data received from an aircraft’s barometric air data sensing instrumentation components is critical for safe flight, and this incident highlights the importance of maintaining a high level of attention to damage and contamination when working on and inspecting these components.”

The ATSB report also notes the flight crew did not notify air traffic control of the altitude discrepancy of 340 ft.

“This discrepancy exceeded the 200 ft maximum allowed altimetry system error for the reduced vertical separation airspace in which they were operating,” Ms Hughes said.

“Flight crews need to advise air traffic control of altimetry system errors, so adequate vertical separation with other aircraft can be assured.”

Since the incident, the maintenance organisation has undertaken several procedural initiatives to reduce the likelihood of melted pitot-static probe covers in the future, including replacing the polyvinyl chloride covers with high temperature resistant Kevlar covers.

Read the report: AO-2022-033 - Unreliable altitude indications, Boeing 737-476SF, ZK-TLJ 167 km west of Meekatharra Airport, Western Australia on 10 June 2022

Publication Date
13/04/2023

 
Hmm...I'll let others more qualified than me make an assessment of the safety value of a report that IMO should have been ticked and flicked five minutes after arriving in the inbox of the desk jockey TSI assigned to this. Also, I guess that 10 months 3 days for completion is sort of tracking towards 7 months...   


MTF...P2 

PS: On the subject of 'Systemic' investigations tracking towards completion inside 20 months, I note that the ATSB has yet again gone past a promised update commitment for the YMEN DFO approval process systemic investigation: https://www.atsb.gov.au/publications/inv...i-2018-010

"..An update on timing for completion of the investigation will be provided at the start of 2023 after the ATSB has been able to complete necessary engagements with Australian and international DIPs..."

[Peetwo]

Without fear nor favour the UK AAIB (point of comparison)?? -   

The following is a no fuss (no bollocks and definitely no attribution; or Director of Transport Safety quotes) AAIB media statement, for a fatal GA VFR into IMC loss of control accident investigation final report, released yesterday...  

AAIB investigation to Mudry Cap 10B, G-BXBU

Loss of control during diversion in poor weather, Lower Colley Farm, Buckland St Mary, Somerset, 12 August 2021.

From:Air Accidents Investigation Branch Published 27 April 2023


Category: General aviation - fixed wing
Report type: Bulletin - Field investigation
Date of occurrence: 12 August 2021
Aircraft type: Mudry Cap 10B
Location: Lower Colley Farm, Buckland St Mary, Somerset
Registration: G-BXBU

Summary:

The pilot found himself stuck above cloud during a cross-country flight under Visual Flight Rules. After contacting the Distress & Diversion Cell for assistance he was transferred to the radar frequency of a nearby airport, at which the cloud base was below the minimum required for the approach offered. The pilot, who was not qualified to fly in cloud, lost control of the aircraft during the subsequent descent and the aircraft was destroyed when it hit a tree. Both occupants were fatally injured.

The investigation found that air traffic service providers did not obtain or exchange sufficient information about the aircraft and its pilot to enable adequate assistance to be provided. There was an absence of active decision making by those providers, and uncertainty between units about their respective roles and responsibilities.

Seven Safety Recommendations are made to address shortcomings identified in the provision of air traffic services in an emergency.

Download report:

Mudry Cap 10B, G-BXBU 06-23

Download glossary of abbreviations:

Glossary of abbreviations

Published 27 April 2023[/font][/color]

The safety recommendations:  

Safety Recommendation 2023-011

It is recommended that the Civil Aviation Authority publish guidance for general
aviation pilots on responding to unexpected weather deterioration, highlighting
the factors affecting their performance and the benefits of planning before the
flight how they will respond.

---

Safety Recommendation 2023-012

It is recommended that the Civil Aviation Authority require air traffic controllers
to receive training regarding the human performance characteristics and
limitations associated with stress. This should include the verbal cues that may
indicate that a pilot is operating under high stress, and mitigation strategies to
help controllers deal with such events.

---

Safety Recommendation 2023-013

It is recommended that the Civil Aviation Authority specify the types of information
that air traffic controllers will obtain and record when responding to aircraft in
an emergency to ensure that pilots’ needs are met and reported correctly if
communicated to other air traffic control units.

---

Safety Recommendation 2023-014

It is recommended that the Civil Aviation Authority encourage the use of
checklists in air traffic management operations when dealing with abnormal and
emergency situations.

---

Safety Recommendation 2023-015

It is recommended that the Civil Aviation Authority determine the effect the
D&D Cell’s executive control has on civil ATCOs and inform civil ATCOs of any
differences in their responsibilities whilst executive control is exercised.

---

Safety Recommendation 2023-016

It is recommended that the Department for Transport review the current provision
of emergency communications in the UK to determine if the involvement of a
dedicated emergency air traffic service unit is the most effective way to assist
civil aircraft in an emergency, and publish its findings

---

Safety Recommendation 2023-017

It is recommended that the Department for Transport specify and publish details
of the emergency air traffic service it requires the D&D Cell to provide.

The AAIB was established in 1915 and since 1983 has been under the Department of Transport control (see HERE). This is how it is constituted today:

The AAIB has 64 employees.[10]

These are:

• Chief Inspector of Air Accidents
  
• Deputy Chief Inspector of Air Accidents
  
• Six teams of inspectors from all disciplines each led by a principal inspector
  

AAIB Inspectors fall into one of three categories:

• Operations inspector – must hold a current Airline Transport Pilot Licence with a valid Class I medical certificate. Able to offer appropriate command experience on fixed-wing aircraft or helicopters. Broad-based knowledge of aviation.
  
• Engineering inspector – must hold an engineering degree and/or be a Chartered Engineer with a minimum of five years' post qualifications experience. Knowledge and experience of modern aircraft control systems.
  
• Flight recorder inspector – degree level in electronics/electrical engineering or an aeronautical engineering related subject and/or is a chartered member of a relevant engineering institute with eight years' experience since qualifying. Knowledge and experience of modern avionics.
  

There is also a Head of Administration who is supported by two teams, the Inspector Support Unit (ISU) who provide administrative support to the principal inspectors and their teams and the Information Unit (IU), who are the first port of call for accidents being reported.

AAIB administrative staff are part of the Department for Transport (DfT) and are recruited according to civil service guidelines.

 
So kind of like our BASI was originally constituted, this small but effective team has the proven and historical runs (108 years) on the board. I say - BRING BACK BASI! 

MTF...P2 

[Peetwo]

APOC: ATSB v TAIC & AAIB - 
First from today's latest flurry of Popinjay AAI activity...

Courtesy of today's Director Transport Safety, Stewie Godlike -   :

Fuel starvation incident highlights importance of proper fuel management



Two pilots experienced engine surging and declared a mayday after inadvertently exhausting the aircraft’s auxiliary tanks, an Australian Transport Safety Bureau investigation notes.

On 18 August 2022, an instructor and trainee instructor were operating a Cessna 310R during a training flight from Redcliffe Aerodrome, Queensland when the engines started surging alternatively.

The instructor declared a MAYDAY and began tracking for a forced landing at Sunshine Coast Airport, but during troubleshooting on descent, the crew switched from the auxiliary to the main fuel tanks, and the engine issues were rectified. The crew then conducted an uneventful landing.

An ATSB investigation found the auxiliary tanks had been exhausted, resulting in fuel starvation and engine surging.

“The pilots did not establish the amount of fuel on board prior to the flight, or manage the fuel state throughout the flight,” ATSB Director Transport Safety Dr Stuart Godley said.

“Both pilots were unaware of the fuel system configuration of the Cessna 310R, believing the aircraft was fitted with larger auxiliary tanks than was the case.”

The incident aircraft had a 140L usable fuel auxiliary tank capacity, but the instructor assumed it had the same 238L capacity as other Cessna 310 aircraft they had flown.

“The ATSB also found the operator had inconsistent and incomplete technical documentation for the aircraft, and the aircraft’s fuel selector plaques contained contradictory and incorrect information about the capacity of the auxiliary tanks, and in different units,” Mr Godley added.

Since the incident, the operator – Aircraft Australia – has implemented a new fuel log specific for the Cessna 310R.

Additionally, an internal memo has been distributed outlining the changes to the data sheet for the Cessna 310R to ensure all pilots and students are aware of the fuel configuration of the aircraft.

The operator has also requested fuel selector plaque replacements, to ensure the correct labels are installed.

Dr Godley welcomed the safety actions taken by the operator, but emphasised the incident’s relevance to all pilots.

“Accidents involving fuel mismanagement are an ongoing aviation safety concern, and are a reminder of the importance of monitoring fuel levels prior to, and during flight,” he said.

A selection of fuel management related incidents, and their safety lessons, have been previously published by the ATSB in the publication Avoidable Accidents No. 5.

Dr Godley also noted methods for cross-checking fuel on board before flight are published by the Civil Aviation Safety Authority in its Advisory Circular AC 91-13v1.1.

Read the ATSB’s report: AO-2022-040 Fuel starvation event involving Cessna 310, VH-JQK, near Sunshine Coast Airport, Queensland, on 18 August 2022

Publication Date 05/05/2023

Note that this 'Short' investigation didn't incorporate a prelim report, so once again relying on the ATSB notified difference to ICAO Annex 13 Ch 7 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.

 
However some kudos to the ATSB needs to be acknowledged for this investigation was completed to a final report inside of 9 months. Whether or not this investigation should have been continued to a final report and yet another concocted, 'attributable to' WOFTAM media report is another matter..?? 

Next I noted the following from the NZed TAIC Linkedin webpages:

Transport Accident Investigation Commission
853 followers
2w •

TAIC report: Safety issues for NZ CAA to resolve: requirements and technical standards for NVIS and helicopter air ambulance; crew resource management training and qualifications for non-pilots acting as crew members; guidelines for crew members assisting a pilot during #NVIS ops.

Misinterpretations by pilot of BK117-C1 helicopter during VFR flight using #nightvision goggles led to controlled flight into terrain (Southern Ocean sea). All 3 on board survived. #training #safety #nvg #airambulance

   
It would appear that the TAIC without 'fear nor favour' is quite prepared to take it up to the NZCAA...

However this post did cop some interesting criticism from a very qualified SME Mr Darren Straker:

Darren Straker
• 2nd

Expert: T/Pilot (CCAR/CS25), Aircraft Level Design, Certification/Development/Flight Test Safety/FltOps Audit/Accident Investigation
2w

This occurred on 22 April 2019? Its now April 2023, read the ICAO Annex 13 requirements for the production of Air Accident Reports 'within 12 months'.

Admittedly, there were logistical and distance constraints, however no analysis requires 4 years.
How does TAIC manage its responsibilities - let alone audit obligations - with a 4 year duration for an accident report?

---

Gerard Robertson
2w

One did wonder.

---

James H.

Still quicker than the ATSB

---

Darren Straker

James H. At least the ASTB know what they're doing and they're accountable. 

4 Years to factor all of that accident safety information back to the CAA and the SMS systems in both organisations is pointless, in contradiction to the States ICAO SARP's, in conjunction with the CAA oversight for the SMS for these 'higher than normal risk' flights.

---

Gerard Robertson

Darren Straker That was really my thinking, too. I would expect that prioritisation of accident investigations might be determined by likelihood of recurrence. Apparently not.

---

Darren Straker

Gerard Robertson TAIC have priority over what they choose to investigate, up to a point. Annex 13 is clear on the risk assessments regarding serious incidents; accidents investigation should be mandatory.

Determining the 'likelihood of a reoccurrence': this was a CFIT over water with degraded visual conditions, this can happen anywhere in an operating environment such as NZ.

If the CAA SMS oversight system was functioning, the recommendations should be factored back into the system, to quote ICAO, ' to prevent a reoccurrence'.

A 4 year lapse is unacceptable nonsense and no-one in the MOT has a clue.

No complex accident investigation should take longer than 12 months, if the budget (NZ$+5 Million p.a.), the staffing levels, experience and capability are as required by the charter.

How many Chief Investigators has TAIC had in the previous 5 or 6 years? Quite a few. The question then is why?

 

Hmmm...maybe the TAIC has some similar operational issues to that of the ATSB but I do question whether the ATSB knows what it is doing and are accountable?? At least the TAIC are directly accountable to a Minister of the Crown: https://en.wikipedia.org/wiki/Transport_...Commission

It was established by Act of the Parliament of New Zealand (the Transport Accident Investigation Commission Act 1990) on 1 September 1990. TAIC's legislation, functions and powers were modelled on and share some similarities with the National Transportation Safety Board (USA) and the Transportation Safety Board (Canada). It is a standing Commission of Inquiry and an independent Crown entity, and reports to the Minister of Transport.

 

Finally I note the following Tweet by the UK AAIB:

AAIB @aaibgovuk · May 3

The AAIB has published a report into an incident involving a Pegasus Quik (G-CGRR) after it tipped over on landing at Harringe Court Farm, Ashford, Kent on 6 August 2022. Read the report https://gov.uk/government/news/aaib-repo...ugust-2022 #AviationSafety

Note that the AAIB had absolutely zero issue with investigating a non-fatal recreational ultralight accident which they completed inside of 9 months and saw no need (other than the Tweet) in using their limited resources in producing a pointless media blurb, rather they rely on their report to highlight the identified safety issues of the investigation...

MTF...P2 

[Peetwo]

ATSB AO-2023-008 (56 day non-compliant with ICAO Annex 13) prelim report review cont/-  

"K" beginning to sort out the 'Wheat from the Chaff':

Of the winnowing of Wheat from Chaff.

One of the most difficult (least liked) jobs we have toiling for Aunt Pru is 'winnowing' – fact from fiction, without friction; agenda from base intent; and rumour from reality. All fraught with peril; particularly the 'rumour' elements. Much depends on 'who' told the tale, their 'agenda' and why. Sometimes, it is no more than a third or fourth hand yarn, embellished for effect; or, for a laugh in the Pub. But, every once a while, a part of a puzzle lands on screen, or the phone rings – and one element, a nugget if you will, of information lands which, stand alone is 'something of nothing', noted and tucked away. Then, there is the 'other' type of rumour; the one which steadily gains credibility through 'source' and diversity of provider. These are the interesting ones – of the no smoke without fire type. They are also problematic for many reasons. For example; 'we' were very interested in the back room rumours emanating from the Coulson 737 fire bombing event.

Bloggs - “I think most of us are sitting quietly shaking our heads, unable to speak or type...

True enough; the wise knew to await the report; the 'safety action' speaks volumes:-

Following the accident, Coulson Aviation issued operations bulletin 2023-01 advising their large air tanker pilots operating in Australia that their minimum retardant drop heights and VDROP air speeds had been increased from 150 ft above ground level and 1.25 VS to 200 ft above ground level and 1.35 VS. Their B-737 normal checklist was amended accordingly to reflect their new minimum VDROP air speeds.

That's biggish lump of machinery to be throwing around, low, slow, heavy, close to the deck in hot bumpy weather, smoke etc, etc. Boeing 'book numbers' are very good for 'normal' operations – but I doubt there is section dedicated to 'agricultural' ops. Perhaps in the 'Sim' and 'on paper' it all looks kosher; but the 'safety' advice reflects what many believe to be the core issue. Clearly, someone wrote the ops spec in use at the time into the 'book' and CASA senior inspectors must have approved it as part of the AOC issue. Looks very much, on the surface at least, that some senior folk who thought it all 'hunky-dory got their collective 'hunks and dory's muddled. Or, did they?  Rumour #1 says perhaps not. That, alone was worth some homework, all the way back to the beginning. So we began digging and rummaging through the history of the application, operational approval and the event.

It has been impossible to gather anything that even vaguely resembles 'fact' let alone 'provable' evidence. Rumour by the cart load, opinion by the bushel; speculation and gossip enough for a small mountain of the stuff. In short; nothing that could withstand a legal challenge. However; there were a few tales from the woods which were at least consistent, a thread running through tapestry which touched the same points. Whether true or false we have no idea; pure speculation and pub conjecture will not pass any legal litmus test. So, dear reader, I shall leave it up to you to decide if there is indeed 'something rotten in the state of Denmark'. Paraphrased below, nut shell version are the most consistent, most reiterated rumours we were offered. True of False – I have no idea. Handing over....

Item 1:- Senior CASA inspectors were, for the reasons stated in the ATSB safety actions, opposed to the issue of the Coulson AOC - as presented.

Item 2:- These worthies were overruled by Reg Services based on preference being given to an opinion based on personal relationship and faith in that element of the equation.

Item 3:- There allegedly exists a small mountain of internal complaints against Reg Services top dogs; the usual stuff alleged bullying, harassment etc, etc. Along with calls for a major change of the top order.

Item 4:- Apparently, the calls for change are ignored by the top floor. Seems that the protection of certain species is a prerequisite of executive KPI bonus for 'diversity'.

These persistent rumours have no supporting evidence non whatsoever. I could even be just making it all up as I go along. Consistency and diversity of source however make one wonder about smoke and fire.

Aye well, no pleasure taken in it all; leaky buckets are of neither intrinsic or practical value. However, duty done and there's an end to it. FWIW.

Toot toot.....

Hmm...in addendum to the above, I note that Popinjay's 'attributable to' comments were reported on by the other Aunty: https://www.abc.net.au/news/2023-05-03/a.../102297164

Australian Transport Safety Bureau finds Boeing 737 crashed into ridge while fighting fire

By Keane Bourke and Grace Burmas

Posted Wed 3 May 2023 at 12:29pmWednesday 3 May 2023 at 12:29pm, updated Wed 3 May 2023 at 4:09pm


The Boeing 737 crashed while fighting bushfires on WA's south coast in February. (ABC News)

Key points:

• The Boeing 737 was fighting a bushfire in WA's south in February
  
• A report says the plane clipped a ridge line, leading to the crash
  
• Miraculously, the pilots escaped through a cockpit window
  

A Boeing 737 firebombing aircraft which crashed in Western Australia's south earlier this year hit a ridge line while dropping retardant, a preliminary investigation has revealed.

The Large Air Tanker, a civilian aircraft that was converted for firefighting and operated by Coulson Aviation, had been helping crews fight a bushfire in the Fitzgerald River National Park when it crashed on February 6.

At the time, the Australian Transport Safety Bureau (ATSB) confirmed it was the first time a 737 had been "lost" in Australia.

Both pilots escaped with minor injuries before most of the huge plane was destroyed by fire, with Premier Mark McGowan describing their survival as a "miracle".

Investigators from the ATSB found the pilots attempted to pitch the plane up from the low-altitude drop before its engines could accelerate, seconds before it hit the ridge line.

"Flight recorder data shows the throttles were advanced and the engines had accelerated just before the aircraft struck a ridge line with the stick shaker activating," ATSB Chief Commissioner Angus Mitchell said.

"The aircraft then cleared a small line of foliage, before impacting the ground a second time and sliding to rest.

"Fortunately, and remarkably, both pilots were able to exit the aircraft through a cockpit window, and suffered only minor injuries."

In its preliminary report, the ATSB said the two pilots had been tasked with tagging and extending an existing retardant line, with a target altitude of 500 feet descending to 400 feet.

Pilots made mayday call

Flight data shows the air tanker emptied three-quarters of its load, before the captain stopped the drop because the retardant line was entering a burnt area.

The pilots then repositioned the aircraft to drop the remaining retardant, which was when the accident occurred.



The report found the co-pilot did not announce any deviations during the accident and later reported they were likely focused on the air speed indicator and radio altimeter.

After they hit the ridge, the aircraft cleared a small line of foliage before impacting the ground a second time and then sliding to rest, with the crew issuing an all-stations mayday call.

Cabin door stuck

"Both pilots were unable to open the cabin door as it had buckled and the co-pilot was unable to open the right-side window," the report read.

Realising the plane was on fire, the captain managed to open the left side window on a second attempt, allowing the pair to escape.

Crews believed the pilots were trapped inside the aircraft and dropped retardant on the tanker, before the duo were rescued by helicopter with minor injuries.

Despite the extensive fire damage to the aircraft, the ATSB was able to download files from both the flight data recorder and cockpit voice recorder.



Investigations are continuing and a final report will be prepared.

"Should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken," Mr Mitchell said.

The ATSB said Coulson Aviation had increased its large air tanker minimum retardant drop heights and airspeeds as a result of the preliminary findings.

Opposition calls for review into firebombers

WA Shadow Emergency Minister Martin Aldridge called for "deep consideration" from the government and regulator over the use of large aircraft to fight bushfires.

"Operating these large air tankers in these types of conditions isn't without risk," he said.

"That's why the opposition has been calling for the government and indeed, the Civil Aviation Safety Authority (CASA) as the regulator, to review the operation of firebombing aircrafts, particularly large air tankers in an Australian context."

Mr Aldridge said he was yet to hear a response from CASA since the crash.

"It will be interesting to see, noting that Coulson themselves have adjusted their operating conditions, whether or not CASA will reinforce those with regulations to ensure that similar aircraft operating within Australian jurisdictions remain safe over fire grounds." - P2: Good questions from that man??

Transport Minister Rita Saffioti said she had not been fully briefed on the preliminary report, but acknowledged the "inherent risks" involved in aerial firefighting.

She said the WA government would "continue to work with the federal government in relation to the safety of our skies".

"In particular, the safety of aerial firefighting, which is now an essential part of managing fires across the state," she said.

It is with a degree of irony that less than 3 weeks before the accident, on the Coulson Aviation webpage, there was this press release: Coulson Aviation Awarded Australian Large Air Tanker Contract Facilitating Continued Support of Bush Fire Season 

..Port Alberni, B.C. – January 17, 2023 – Coulson Aviation is excited to announce it has been awarded the contract for Australia’s National Large Air Tanker (LAT). The converted Boeing 737, Tanker 139, is the newest addition to Coulson’s FireLiner™ fleet and will be based in Sydney, New South Wales but will support additional locations in-country as needed. As the National LAT, Tanker 139 will wear the name “Phoenix” as a result of a naming competition last year via local Australian schools and joint winners Bishop Druitt College Coffs Harbour, St Patrick’s College Campbelltown, and Christian College Geelong.

“Coulson is proud to provide our state-of-the-art aircraft to the Federal Australian Government. This aircraft is an incredibly efficient bomber and the crews that operate each of our aircraft are second to none,” said Coulson Aviation Australia CEO Britt Coulson. “Working alongside dedicated Australian firefighters, Phoenix will be one of the key assets supporting this upcoming bush fire season,” said Britt...

Let us not forget that the man who was accused by Bruce Rhoades (may he RIP -  ) in conducting a 'Venomous, Vicious, Vindictive and Vexatious' campaign against him and his flight adventure business...

 

...was appointed last year as the COO of Coulson Aviation Australia.

Again, via the Coulson website: https://coulsonaviation.com.au/new-chief...australia/

..Coulson Aviation Australia is excited to welcome Craig Martin to the role of Chief Operating Officer (COO).

Craig is the former Executive Manager of Regulatory Oversight at Australian federal aviation regulator Civil Aviation Safety Authority (CASA) and brings more than 30 years of experience in the aviation sector.

Coulson Aviation Australia CEO Britt Coulson said Craig is a welcome addition to the organisation, which continues to grow and evolve its business in Australia.

“It’s a pleasure and an honor to have Craig as part of our team. He brings a deep knowledge and practical understanding of the new CASA Flight Operations Regulations which we believe will enable Coulson Aviation to expedite the building of a strong national aerial firefighting fleet in support of the Australian Federal, State and Territory governments,” he said.

“A key focus for Craig will be supporting the needs of NSW Rural Fire Service, and ensuring the expansion of our organisation continues to meet the regulatory and safety outcomes required of operators authorised by CASA to develop national aerial firefighting capability...

Finally (for now) I note the following CASA legislative instrument exemption awarded to Coulson and signed by the former holder of stakes Executive Manager and now the 'Regulatory Oversight' EM (IE CM's former role: https://www.casa.gov.au/about-us/who-we-...xt-version) Rob Walker: https://www.casa.gov.au/fixed-wing-firef...aviation-0







Note that this exemption was apparently repealed on the 30 June 2022??   

MTF...P2 

[Peetwo]

Juan Browne review of AO-2023-008 prelim etc. - ?? 

Via the blancoliro YouTube channel:  

On that exemption?? 

Remember this from, a month before Rob Stakeholder Walker signed that exemption...  

Walker to take over Oversight as Crawford departs CASA



Executive Manager Stakeholder Engagement Rob Walker is set to take over the Regulatory Oversight Division in a new CASA structure that has also seen Group Executive Manager – Aviation Graeme Crawford leave the regulator after his position was abolished.

Walker has run the Stakeholder Engagement division since March 2016 and has been instrumental in reforming consultation processes and establishing the Aviation Safety Advisory Panel and Technical Working Groups.

The new structure has been put in place by Director of Aviation and CEO Pip Spence in order to flatten the management structure and focus all divisions of CASA on aviation safety.

All executive managers will now report directly to Spence with the Regulatory Oversight Division (ROD), National Operations and Standards, and Group Transformations and Safety Systems joining the CASA executive committee.

In a statement handed to all CASA staff on 5 October, Spence explained the reasoning behind the changes.

"An 'aviation group' with its own executive team implies a split from the rest of the organisation and doesn't properly acknowledge that was are all here to work together in the interest of aviation safety.

"At times, this has impeded organisational efficiency and made it more difficult for our whole executive to achieve alignment on important issues."

Spence acknowledged the work of Crawford pointing our his contribution to regulatory reform and his tenure as Acting Director of Aviation Safety following the retirement of Shane Carmody late last year.

Sources within CASA have said that previous ROD Executive Manager Craig Martin is due to leave the regulator by the end of October.

Ah yes the Board and Pip Spence decision to flatten the executive management structure...

However you've got to question what they were thinking when they decided to put a career stakeholder engagement bureaucrat, with absolutely zero industry experience in such matters, as the executive manager of the regulatory oversight division??

And then less than 3 weeks into the job he signs off on the Coulson Exemption.

Given this was a Federal Govt contract and also the political sensitivity around bushfires at the time, it would be fair to assume that the former EM of the ROD, Craig Martin had been personally overseeing the processing of this exemption. Then as a passing strange coincidence three months later CM ends up in the position as the Chief Operating Officer at Coulson...

Finally I refer you back to the "K" Blah_wich rumour post: Of the winnowing of Wheat from Chaff.

A timeline of coincidence or a timeline of convenience?? 

MTF? - Indeed much!..P2   

   
PS: Next - What that exemption actually meant; how it would have been processed; and what has happened to it now (IE has it been incorporated into the COM)??

[Peetwo]

NSW Coroner drills a hole through the Sydney Seaplane crash Federal obfuscation??? 

Via the Oz:

Disturbing twist to Sydney Seaplane crash that claimed six lives



An aircraft maintenance company at the centre of a fatal Sydney Seaplane’s crash continues to operate with Civil Aviation Safety Authority approval, despite failing to address work practices that contributed to the tragedy.

Airag Aviation Services was found to have used non-standard bolts and other non-standard materials in its maintenance of the crash aircraft — a DHC-2 Beaver floatplane.

As a result it was believed three of the bolts securing a firewall had come out, allowing carbon monoxide fumes to enter the plane’s cockpit during a return trip between Rose Bay and Cottage Point on December 31, 2017.

The Australian Transport Safety Bureau found carbon monoxide poisoning most likely led to pilot Gareth Morgan becoming disoriented, and crashing into Jerusalem Bay.

The impact killed all six people on board, including Mr Morgan and British tourists Emma Bowden and daughter Heather, 11, Richard Cousins and sons William and Edward.

It wasn’t until two years after the crash that it occurred to the ATSB to test the victims for carbon monoxide, with the results showing all had elevated levels of the toxic gas in their blood.



Maintenance issues that led to the gas leak were identified in the final ATSB report released in January 2021 but no safety direction was made specifically for Airag.

Throughout the investigation and since, Airag has continued to work on commercial aircraft despite making little apparent effort to change its practices that allowed the use of non-standard parts such as bolts and pipes.

The situation was highlighted in a report by NSW deputy state coroner Derek Lee who confirmed the ATSB’s findings that carbon monoxide poisoning was the likely cause.

Magistrate Lee also noted remedial action taken by Airag since December 31, 2017 had been “extremely limited and in essence confined to oral instructions which are lacking in detail”.

“(These instructions) have not been reduced to writing or developed into any robust policy,” he wrote.

“The evidence suggests that the response by Airag is antiquated and not informed by contemporary practices. The response also does not demonstrate an attitude and approach to supervision and safety that is consistent with the expectations of the industry.”



The Civil Aviation Safety Authority indicated Airag was subject to surveillance and regular audits, like any other holder of a CASA-issued operator certificate.

“Following the publication of the coronial report, CASA is considering the Coroner’s reasons, including any new information disclosed as a result of the coronial process, and will evaluate if further regulatory action is warranted,” said a CASA spokesman.

“Any safety findings raised must be followed up and satisfactorily addressed by operators.”

Airag Aviation CEO David Pyett did not respond to calls from The Australian.

Sydney Seaplanes sued Airag Aviation following the release of the ATSB report and the case was settled out of court last year.

Managing director of Sydney Seaplanes Aaron Shaw said they remained “very, very angry” about what had happened on New Year’s Eve in 2017.

“It’s resulted in the death of a dear colleague of ours and caused untold grief for many other families,” Mr Shaw said.

“We are also victims of this accident. It’s caused us reputational damage, financial damage and for there to be effectively no consequences or actions (for Airag) beggars belief.”

He said the tragic matter also called into question the role of the aviation safety regulator.

“I don’t think expectations are being met by the lack of action being taken, from what we can see,” said Mr Shaw.

“I think the community would expect a more proactive response to the various reports made about this accident.”

MTF...P2 

[Peetwo]

NSW Coroner drills a hole through the Sydney Seaplane crash Federal obfuscation? - Part II

Via the Oz:

Disturbing twist to Sydney Seaplane crash that claimed six lives



An aircraft maintenance company at the centre of a fatal Sydney Seaplane’s crash continues to operate with Civil Aviation Safety Authority approval, despite failing to address work practices that contributed to the tragedy.

Airag Aviation Services was found to have used non-standard bolts and other non-standard materials in its maintenance of the crash aircraft — a DHC-2 Beaver floatplane.

As a result it was believed three of the bolts securing a firewall had come out, allowing carbon monoxide fumes to enter the plane’s cockpit during a return trip between Rose Bay and Cottage Point on December 31, 2017.

The Australian Transport Safety Bureau found carbon monoxide poisoning most likely led to pilot Gareth Morgan becoming disoriented, and crashing into Jerusalem Bay.

The impact killed all six people on board, including Mr Morgan and British tourists Emma Bowden and daughter Heather, 11, Richard Cousins and sons William and Edward.

It wasn’t until two years after the crash that it occurred to the ATSB to test the victims for carbon monoxide, with the results showing all had elevated levels of the toxic gas in their blood.



Maintenance issues that led to the gas leak were identified in the final ATSB report released in January 2021 but no safety direction was made specifically for Airag.

Throughout the investigation and since, Airag has continued to work on commercial aircraft despite making little apparent effort to change its practices that allowed the use of non-standard parts such as bolts and pipes.

The situation was highlighted in a report by NSW deputy state coroner Derek Lee who confirmed the ATSB’s findings that carbon monoxide poisoning was the likely cause.

Magistrate Lee also noted remedial action taken by Airag since December 31, 2017 had been “extremely limited and in essence confined to oral instructions which are lacking in detail”.

“(These instructions) have not been reduced to writing or developed into any robust policy,” he wrote.

“The evidence suggests that the response by Airag is antiquated and not informed by contemporary practices. The response also does not demonstrate an attitude and approach to supervision and safety that is consistent with the expectations of the industry.”



The Civil Aviation Safety Authority indicated Airag was subject to surveillance and regular audits, like any other holder of a CASA-issued operator certificate.

“Following the publication of the coronial report, CASA is considering the Coroner’s reasons, including any new information disclosed as a result of the coronial process, and will evaluate if further regulatory action is warranted,” said a CASA spokesman.

“Any safety findings raised must be followed up and satisfactorily addressed by operators.”

Airag Aviation CEO David Pyett did not respond to calls from The Australian.

Sydney Seaplanes sued Airag Aviation following the release of the ATSB report and the case was settled out of court last year.

Managing director of Sydney Seaplanes Aaron Shaw said they remained “very, very angry” about what had happened on New Year’s Eve in 2017.

“It’s resulted in the death of a dear colleague of ours and caused untold grief for many other families,” Mr Shaw said.

“We are also victims of this accident. It’s caused us reputational damage, financial damage and for there to be effectively no consequences or actions (for Airag) beggars belief.”

He said the tragic matter also called into question the role of the aviation safety regulator.

“I don’t think expectations are being met by the lack of action being taken, from what we can see,” said Mr Shaw.

“I think the community would expect a more proactive response to the various reports made about this accident.”

Via the NSW Coroner's website: https://www.coroners.nsw.gov.au/coronial...archPage=1#

• Inquest into the deaths of Emma Bowden, Heather Bowden-Page, Edward Cousins, Richard Cousins, William Cousins &amp; Gareth Morgan- external sitelaunch
  Decision of Deputy State Coroner Lee
  CORONIAL LAW - cause and manner of death, aviation fatality, de Havilland Canada DHC-2, Jerusalem Bay, Sydney Seaplanes, Airag Aviation Services, floatplane, engine exhaust system, magneto access panels, magneto cooling tubes, firewall breach,
  

Remember this 'update' from the ATSB FR: https://www.atsb.gov.au/publications/inv...o-2017-118

Update: 3 July 2020

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

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

Since receiving the toxicology results, the ATSB has:

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

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

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

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

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

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

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

Despite the inexcusable fact it took the ATSB the better part of 2 years to discover that there had been no toxicology testing for CO, the Deputy Coroner went easy on the ATSB but his findings and recommendations went to the issue with other directly involved government agencies: Ref from page 57






Read between the lines on the Deputy Coroner's observations on the regulator...










It continues on and IMO is well worth the read - top job that Coroner...

Much MTF??..P2 - 

PS: Reflect on this post from August 2019 - Hooded Canary not singing but still talking bollocks - and consider how things have improved in the nearly 4 years since - err NOT! 

[Peetwo]

Popinjay issues an Occurrence Brief for GA-8 Airvan Operators?? -   

Via Social media:

Australian Transport Safety Bureau

The ATSB has published an occurrence brief after the rear cabin door of a GippsAero GA8 Airvan separated and fell from the aircraft during a scenic flight at Fraser Island, Queensland.

Apparently this is what the ATSB define an OB as:

Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.

The disconnections??

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report and allow for greater industry awareness of potential safety issues and possible safety actions.

This is the 2010 CASA AD referred to: https://services.casa.gov.au/airworth/ai...A8-003.pdf

 

Background: Inspections have revealed cases of excessive wear in the forward slide of the cargo door. Excessive wear in the door slide may result in the door becoming detached from the aircraft in flight, with potentially catastrophic results. Following a recent in-flight door separation, this amendment is issued to update the service bulletin to remove any ambiguities that could have existed in the previous revision to the referenced service bulletin. It also provides an improved inspection method and a minor design change to the cargo door slide (inclusion of slide backing plate, castellated nut and spilt pin).

So despite the above AD information being freely available via a 10 second Google search, Popinjay (or one of his minions) decides not to investigate but instead issues a notification (via social media) of an OB 83 days after the incident occurred. Yet according to the OB (ref: https://www.atsb.gov.au/publications/occ...april-2023 ) the actual brief was created nearly two weeks ago??   

MTF...P2 

PS: Strangely there is no words of wisdom, in what is now a Popinjay SOP media release, from whoever is this week's DTS??

[Kharon]

The five year itch.

After the Ross Air loss of three men and a Cessna 441 airframe; the ATSB took 1067 days to produce 'a report' – HERE -.

2017 - Oz Flying: “An investigation report released today into the fatal crash of a Cessna 441 near Remark, SA, in 2017 has identified a failure to maintain speed and subsequent loss of control as causes.”

P2 kicked off the forum 'discussion' – HERE - .

Fast forward to 2023 AD.

2023 - The Australian Transport Safety Bureau (ATSB) is seeking to clarify with operators of the twin-engine Cessna 441 aircraft the recommended procedures for conducting simulated engine failure exercises with a view of removing any doubt as to how the aircraft’s manufacturer, Textron, believes these types of exercises should be safely and effectively conducted. Etc.....

If one takes a quick, cursory read it is all too easy to dismiss the 'clarification' blurb as the usual pointless, little value waffle we have come to expect from Popinjay's ATSB. Click/flick and back to your knitting. -  Mistake...

Take a look through your CASA approved check/training system; then carefully read through the type rating and proficiency check systems – then ask who, exactly approves and in the Ross Air case sat in on the exercise, to ensure that all requirements (CASA demanded and enforced) are met, all the boxes ticked and etc.. Then wonder no more as to why ATSB have generated this pointless load of cobbler's.  Top cover - anyone?

Toot – toot – (MTF? You bet)...

[Peetwo]

WOW! Popinjay produces a short investigation report inside 8 months?? - 

Via PJ HQ, attributed to this week's Director Transport Safety Kerri Hughes:

Trans-Tasman engine failure event highlights benefits of effective decision making



A 737 flight crew’s response to an engine failure over the Tasman Sea earlier this year highlights the benefits of effective decision-making and management of an unexpected situation, an Australian Transport Safety Bureau investigation notes.

During a scheduled passenger flight from Auckland to Sydney on 18 January 2023, the left engine of a Qantas-operated Boeing 737-838 shut down uncommanded.

In response, the flight crew declared a MAYDAY to prioritise communications with air traffic control, and to ensure they were cleared for an immediate descent from 36,000 ft to 24,000 ft.

The left engine could not be restarted in-flight, and the flight crew conducted an uneventful single-engine landing at Sydney Airport about an hour later.

“A subsequent engine teardown inspection identified separation of the radial driveshaft in the engine’s inlet gearbox, which resulted in a mechanical discontinuity between the engine core and accessory gearbox,” ATSB Director Transport Safety Kerri Hughes said.

“Loss of drive to the accessory gearbox resulted in a loss of fuel pump pressure and uncommanded shutdown of the engine.”

At the time of the engine failure, the aircraft was around 150 km closer to Norfolk Island than it was to Sydney Airport. However, a diversion to Norfolk Island would have required a deviation from the aircraft’s current track, and Norfolk Island presented changeable weather and operational conditions.

“In contrast, Sydney Airport was on the aircraft’s direct route, had favourable weather conditions forecast, had an extensive emergency response, and a straight-in approach on a very long runway,” Ms Hughes noted.

“The decision to continue to Sydney ensured no additional risk was added to an already high workload situation.”

Separately, the report notes that the aircraft’s cockpit voice recorder was inadvertently overwritten during maintenance activities after the aircraft arrived at Sydney.

Since the occurrence, Qantas has enhanced its procedures to prevent inadvertent overwriting of cockpit voice recorders and flight data recorders.

Read the report: Engine failure involving a Boeing Company 737-838, VH-XZB en route from Auckland, New Zealand to Sydney, New South Wales, on 18 January 2023.

Publication Date
03/08/2023

Plus via Oz Aviation: https://australianaviation.com.au/2023/0...obe-finds/

...The report also separately revealed how the aircraft’s cockpit voice recorder was inadvertently overwritten during maintenance activities after the aircraft arrived in Sydney.

Since the occurrence, Qantas has enhanced its procedures to prevent inadvertent overwriting of cockpit voice recorders and flight data recorders.

Qantas will now ensure that when a request is received to secure the cockpit voice recorder and/or flight data recorder, the following steps are to be carried out:

• Immediately notify the duty technical manager to raise a task in the maintenance software to have the requested item quarantined (or at a minimum, power to the recorders is to be removed).
  
• Follow up with a telephone call to the respective port and ensure the ground engineer is advised of the limited timeframe to secure the data.
  
• Continually follow up with the applicable ports until positive confirmation of the requested action has been confirmed.
  

Hmm...wonder if the Qantas crew simply didn't contemplate that the ATSB would want to actually review the CVR recordings because normally they just copy & paste the internal Qantas SMS investigation report?? -   

MTF...P2 

[Peetwo]

WOW! PJ produces a defined investigation inside 10 months??

Via PJ HQ from this week's attributed to DTS Stewie Macleod...

Flight below minima incidents highlight data entry risks



Two separate occurrences in which 737 airliners flew below minimum altitude on the same arrival and approach into Cairns Airport, demonstrate the risks associated with data entry errors, and the importance of thorough and independent cross-checks.

The Australian Transport Safety Bureau launched an investigation after being notified of two separate incidents, on 24 and 26 October 2022, involving Boeing 737-800 – one operated by Virgin Australia in dark night conditions, the other by Qantas in clear day conditions – on scheduled passenger flights to Cairns, Queensland.

In each occurrence flight crews entered the same standard arrival (HENDO 8Y) and approach (RNP Y runway 33) into their flight management computers.

However, neither flight crew selected the required approach transition resulting in a discontinuity in the programmed flight path.

When presented with the discontinuity by the flight management computer, both flight crews resolved it by manually connecting the arrival waypoint HENDO to the intermediate approach fix waypoint, noted on the approach chart.

This inadvertently removed the 6,800 ft descent altitude constraint associated with the initial approach fix waypoint in each aircraft’s programmed flight path, and as a result both aircraft descended below that constraint.

The Qantas crew recognised the descent error and stopped further descent, while in both cases air traffic control also alerted the flight crews of their low altitude.

The Virgin aircraft conducted a missed approach before conducting a second approach and landed without incident. Air traffic control provided the Qantas crew with clearance for a visual approach, before the aircraft landed without further incident.

”These occurrences highlight the risks associated with data entry errors that result in incomplete or incorrect information being entered in flight management systems,” said ATSB Director Transport Safety Stuart Macleod.

“While no-one is immune to these errors, the risk can be significantly reduced through thorough and independent cross-checks between pilots.

“Good communication, adherence to operating procedures, and clear and effective procedure chart design are crucial to safe flight.”

The investigation also found that the vertical profile depiction on the Jeppesen RNP Y runway 33 approach chart did not include the waypoints HENDO, CS522 and CS523 and the map presented the information associated with those waypoints over dense topographical information.

This likely limited the ability of both crews to identify the descent restrictions associated with those waypoints.

Read the report: Flight below minimum altitude occurrences, 40 km south of Cairns Airport, Queensland on 24 and 26 October 2022

Publication Date
08/08/2023

P2 note: From some personal experience, for more than 20+ years that approach from the south has always been problematic due to it's proximity to Bartle Frere (QLD's highest mountain) and the fact that the descent transition is initially a step down approach rather than a consistent stabilised approach. It is also an approach that very rarely gets used due to the predominant winds being from the SE for all but the 2 to 3 months at the start of the wet season when occasionally you a get a NW wind strong enough to justify using RW33. Can't understand how it is not possible (in this day and age) that with a little tweaking a stabilised approach could not be designed to get around the high bricks to the south of Cairns??  

MTF...P2 

[Wombat]

P2 - something similar occurred mid 1970's. B727 two similar approaches, one with local Dme, t' other with international dme. Plates almost identical. The Captain calculated the impact point was about 200ft below the summit if you navigated by the wrong plate as the FO had almost done. Solution was allegedly different colors.

[Peetwo]

POPINJAY TO THE RESCUE!!?? (yet again -   )

Via PJ bollocks media release HQ yesterday:

ATSB issues advisory notice to aircraft lifejacket manufacturers and certifying authorities



The ATSB has issued a Safety Advisory Notice to both aircraft lifejacket manufacturers and national aviation certification authorities encouraging them to provide guidance to aircraft operators about how to fit a constant wear lifejacket so that it does not interfere with the proper fitment of seatbelts.

The Safety Advisory Notice has been issued as part the ATSB’s on-going investigation into the mid-air collision of two scenic flight helicopters at the Gold Coast on 2 January this year.

During the course of the investigation the ATSB has identified a potentially common lack of understanding in the broader helicopter tourism community about how ‘constant wear’ lifejackets should be worn in conjunction with seatbelts.

“Our investigators have identified that some passengers’ seatbelts in both helicopters involved in this accident were not fitted correctly, in part due to interference from their lifejackets,” said ATSB Chief Commissioner Angus Mitchell.

“However, it is very important to stress we have not attributed the outcomes from this tragic accident to the fitment of seatbelts and lifejacket interference, as the nature of the second helicopter’s collision with the sandbar would typically be non-survivable, and a range of other factors beyond seatbelts contribute to occupant safety in aircraft accidents.

“But our investigation has identified that there appears to be a broader issue across the scenic flight industry where there are misunderstandings as to how seatbelts and lifejackets should be worn.”

Mr Mitchell said an ATSB review of social media photos of passengers of helicopter tourism operations, both in Australia and internationally, established that incorrect fitment of seatbelts with constant wear pouch style lifejackets was prevalent.

Many relevant social media photos reviewed by the ATSB showed the seatbelt webbing or buckle was positioned above the lifejacket pouch or over it. This meant that the lap belt portion of the seatbelt was not low and tight across the passenger’s hips and was positioned either over the lifejacket, creating slack, or above the lifejacket, close to the passenger’s sternum increasing the risk of injury.

“This suggests there is a common lack of understanding in the helicopter tourism community, worldwide, about how to integrate constant wear lifejackets with seatbelts, so as not to reduce their effectiveness.”

Mr Mitchell said the ATSB has identified that lifejacket manufacturers and regulatory authorities have not provided any readily-available guidance to assist helicopter operators on how to position a pouch or yoke style constant wear lifejacket so as not to interfere with an aircraft seatbelt.

“Aviation lifejacket standards require operational instructions be provided in writing and on the lifejackets themselves. For constant wear lifejackets, it is reasonably foreseeable that they would be worn seated in an aircraft and while using the aircraft’s seatbelt. Yet there are no required instructions related to this in the relevant standards and the ATSB found no manufacturers opting to provide instructions.

“The ATSB encourages manufacturers of constant wear lifejackets to provide operating instructions and/or guidance material to operators of aircraft on how to wear and use a constant wear lifejacket with a seatbelt such that it does not interfere with the performance of the seatbelt during an accident,” he said.

“Further, the ATSB encourages certification authorities to modify lifejacket standards to include the requirement for instructions on how to wear constant wear lifejackets while seated and wearing a seatbelt.”

Read the Safety Advisory Notice: Fitment of constant wear lifejackets with seatbelts in aircraft

Publication Date
20/09/2023

And from the SAN: https://www.atsb.gov.au/publications/saf...s-aircraft

What the ATSB found

Passenger photographs and footage from inside both helicopters identified that some passenger seatbelts were not fitted correctly. This was due, in part, to interference caused by the location of the constant wear pouch style lifejackets that were being worn by passengers. The operator’s pre-flight passenger safety briefing video also depicted incorrect use of the 4-point restraint while wearing the lifejacket. The operator’s ground crew, who had been assigned responsibility for the fitment of passenger seatbelts, also indicated in interview that they were not aware that fitting the seatbelt over or above the lifejacket may reduce its effectiveness.

To establish the extent of the issue the ATSB conducted a review of helicopter tourism operations in Australia and around the world through social media. The ATSB found that similar practices of incorrect fitment of seatbelts with constant wear pouch style lifejackets were prevalent. Many relevant social media photos reviewed by the ATSB (see Figure 4 for some examples) showed the seatbelt buckle was positioned above the lifejacket pouch or over it. This meant that the lap belt portion of the seatbelt was not low and tight across the passenger’s hips and the seatbelt buckle was positioned either over the lifejacket (creating slack) or above the lifejacket, close to the passenger’s sternum increasing the risk of injury. This suggests there is a common lack of understanding in the helicopter tourism community about how to integrate constant wear lifejackets with seatbelts, so as not to reduce their effectiveness. Although social media images reviewed by the ATSB predominately showed interference caused by a ‘pouch style’ constant wear lifejacket, the ‘yoke style’ constant wear lifejacket more often used by pilots and commercial passengers, was also shown to have the potential to interfere with the aircraft seatbelt.

For constant wear lifejackets, it is reasonably foreseeable that they would be worn seated in an aircraft and while using the aircraft’s seatbelt. The ATSB reviewed existing guidance from all known manufacturers of aviation constant wear lifejackets, as well as from the Civil Aviation Safety Authority and a range of international aviation regulators. Beyond stating that lifejackets should not interfere with other aircraft equipment, lifejacket manufacturers and regulatory authorities have not provided any readily available guidance to assist helicopter operators on how to position a pouch or yoke style constant wear lifejacket so as not to interfere with an aircraft seatbelt. Additionally, there are no requirements to provide such instructions in the relevant standards.

Hmm...wonder why a 'critical' or 'significant' safety issue notice, accompanied by a safety recommendation, was not addressed directly to the Australian aviation regulator? Shirley this falls directly into the area of CASA's oversight and surveillance of EP's covered under CAO 20.11?

MTF...P2 

PS: Under CAO 20.11 the fitment of the life jackets on the pax is not, from my interpretation, actually required for the helo scenic flight ops, so this is a placebo measure only that has probably been encouraged by CASA without realising that they have inadvertently created a safety risk issue in the process.  Interesting scenario??

[Kharon]

Just my opinion, on the search for probity:-stray thoughts -FWIW..........

Reality v ignorance: official ass cover and insurance placebo.

Quickly and easily any one of dozens of videos may be sourced on 'the net' related to underwater escape from an aircraft, particularly from helicopters. People who travel by and operate choppers to ocean oil rigs, ships etc (etc.) take this all very, very seriously and adapt procedure to meet 'conceived' risks. If you must ask why, stop reading.

In the video, it all seems calm, orderly and well managed and so it is in the 'tank'. However, the underpinning message of the training is vital, valid; understanding, practice, habit familiarity with the 'how/what and when/ why' is quintessential. One could spend a lifetime flying between 'home' and rig and back again, without even spilling your coffee, less risk than the bus ride to the airport. Then again:-

There are factors involved here of which the average mug punter will have no idea, nor the tools and training to deal with. Military and 'off-shore' crew do; even so, the shock of and disbelief in the fact that the aircraft is actually 'in trouble' must be quickly overcome and training must take over; best use of time available an essential . Even then - with fully trained, disciplined, fully aware personnel:-

02 Aug. 2023. Taipan – 4 dead.  - 27 Aug. 2023..Bell Boeing V-22 – 3 dead.

The impact forces are scary, the chance of injury very real and the ability to function effectively under water, under threat, in pain/shock, possibly, upside down in the dark demand much: a much not readily available to the average joy flight thrill seeker.. When you get down to it, for most it will a first ride in a 'chopper' or 'light aircraft'; and, they have absolutely no idea how quickly it can all turn to worms......or even remotely have any real expectations of. Nor should they, in the normal run of the mill outing.

Operators should (and mostly do) know better. Aircraft are excellently maintained; the crew trained and checked; the procedures to ensure safety are enforced, scrutinised and made into law, often with serious penalty attached. Meticulously followed, even if grumbled about – safe as houses 99.999% - the safety record speaks volumes.

P2 - ” Interesting scenario??

P2 - “Hmm...wonder why a 'critical' or 'significant' safety issue notice, accompanied by a safety recommendation, was not addressed directly to the Australian aviation regulator? Shirley this falls directly into the area of CASA's oversight and surveillance of EP's covered under CAO 20.117.?”

P2 - “Under CAO 20.11 the fitment of the life jackets on the pax is not, from my interpretation, actually required for helicopter scenic flight ops, so is this is placebo measure only, one that has probably been encouraged by CASA without realising that they have inadvertently created a safety risk issue in the process. ('K' edit).

Interesting question – 'to have or not to have' - that is the question. But this a scenario which raises more questions than answers and a 'blanket' answer presents some flaws in the 'survivability' equation. Survival of all is the target; there we have half a dozen passengers; call it a broad selection of the public. The life 'jacket' is strapped to the waist. So, the aircraft is going down - Water landing imminent.    - What to do? Unfasten the seat belt, open the 'packet' don the packaged life preserver, fit it correctly, not pull 'the tag' and then strap back in again, await for the Brace call then' evacuate' cleanly? How many 'off the street' folk could even respond, let alone do that within the few seconds allotted between one chopper hitting another and landing 'in the drink'? Not too bloody many.

Yes, it is a 'one-off' - rare (ultra) event; off the charts really. You see, in a routine situation; say engine failure – the crew can (for this discussion) usually manage to get the thing back on the deck without too much 'serious' risk if some 'control' is available– even on water, with self deploying floats. It is a 'nasty' situation but the percentages of survival have been (arguably) demonstrated many times..... But.

There are two things which really beat me; and, a third which leaves me wondering about the 'quality' of safety thinking from the domestic 'authorities' across the spectrum.

In primus, though I hesitate to use the word 'deception' , it sort of fits. Perhaps artificial, or even superficial may suit my purpose best; to explain why the safety measures in place failed and lives were lost – innocent lives, lives of those who 'trusted' the system. Nothing is absolutely 'safe'. But to place the ultimate, last chance of survival, after a short notice of a 'crash' into water, effectively using the allocated 'preserver' of life? Bets on any real safety benefit are at short odds.

The almost worst, unthinkable happened on the Gold Coast. Luck (or as fate would have it) spared the life of one pilot. The other aircraft was out of control, at low level. What chance did the survivors have to undo seat belts, open their 'fanny pack' don their life jackets, re-buckle their belts and 'Brace' for the uncontrolled ditching. (Movie script FCOL). What was the point in providing these things for a five minute flight over inland water; close to a heavy populated, busy, boat crowded shore? Surely a properly adjusted seat belt, sans the 'pack' would have been more beneficial at impact, considering the altitude, time available, lack of notice. Perhaps – probability; and, even 'bullet proof' separation procedures and more time allocated could have been financially justified and officially considered? – Just to be sure; to be sure?

In secundus; why were the scripted operational requirement for the use of these 'life -jackets' approved by CASA for this specific operation? The reality of time required to unpack and 'don' the jacket, the altitude of the flights, the length of the over water segment exposure, the assistance available and the inability of a passenger to complete the required tasks, prior to alighting on water make a complete nonsense of any 'operational oversight'. Has the operator simply gone along with 'the  requirements' as stated to gain operational approval; tick, flick and do. Thumb in bum; mind in neutral from then, and passive acceptance of any dictates imposed.

To crown this glowing, real life glowing achievement; long after the fact, we have the ATSB band wagon 'suddenly' taking a voice, with 'Popinjay' in the media, mouthing a senseless take on an item which should have been considered years ago. The self promotion of this man beggars belief; the 'safety' considerations should (and probably were) documented long ago, by someone with a handle on what 'real life' safety system management should be. Take a quick tour of how a 'real' (cash and no horse-pooh) safety operation  works. The Canadians (once again) – professional, on time, on the money, on budget, get the right job done, no fanfare – just a great 'lesson' for thoughtful, safety conscious folks to contemplate and adopt.

Before anyone starts allocating 'blame' or 'piggy-backing' on tragedy; perhaps it is time to do an 'in depth' on just how hidebound thinking and box ticking convenience is being foisted on the travelling public by our self appointed 'experts'. Re-boot and reality fix required methinks.

Toot (in my opinion) – toot............

[Peetwo]

Chalk and cheese: HLS propwash safety mitigation in the real World?? 

Remember this?

AD-2022-001: Safety risks from rotor wash at hospital helicopter landing sites - Final report 



On Wednesday Dr (Lies, damn lies and statistics) Godlike, this week's attributable to DTS, issued this presser in relation to the release of AD-2022-001 data and analysis final report... :

ATSB issues safety advisory after series of rotor wash injuries at hospital helicopter landing sites



The Australian Transport Safety Bureau has issued a safety advisory after a number of occurrences in which pedestrians were injured by rotor wash around hospital helicopter landing sites.

The notice advises medical transport operators and hospital helicopter landing site operators to engage with one another and ensure local procedures are sufficient to mitigate the risk of rotor wash associated with larger helicopters, such as the Leonardo Helicopters (AgustaWestland) AW139.

It stems from an ATSB Aviation Data and Analysis Report analysis of a series of incidents over the last five years, which considered the common factors, existing regulatory guidelines, and ways to mitigate the effects of rotor wash.

“Of the 18 helicopter rotor wash incidents reported to the ATSB in the last five years, nine occurred at hospital landing sites,” ATSB Director Transport Safety Dr Stuart Godley said.

“Six of those nine occurrences resulted in injuries to pedestrians who were within approximately 30 m of the landing site, and flight crew were not aware of the presence of pedestrians in all cases.

“In fact, in most instances, flight crew were not aware any incident had occurred at the time.”

Significantly, there were no reported occurrences of rotor wash related injuries at hospital HLS prior to the notable increase in the utilisation of AW139 for medical transport operations from 2017.

If the recommended rotor wash exclusion area for the AW139 had been applied at each HLS, it would have reduced the risk of the pedestrians being injured.

The ATSB’s report notes a range of key factors contribute to the effects of rotor wash, including the weight and size of the helicopter, the main rotor size, disc loading, prevailing winds, and flightpath.

“The flightpath is the only element that can be managed by the pilot in accordance with the operator’s procedures,” Dr Godley said.

“But as these occurrences demonstrate, pilots may be unaware of the presence of pedestrians in the vicinity, and therefore be unable to adjust their flightpath accordingly.

“As such, hospital landing site owners and helicopter owners should ensure pedestrians are not affected by rotor wash, by implementing appropriate risk controls for their landing sites, in addition to the helicopter operating procedures.”

Risk controls may include physical barriers, warning devices such as sirens, lights, high visibility warning signs, painted lines on nearby public thoroughfare to alert pedestrians to the rotor wash danger area, an inspection schedule for the landing site facility and surrounding area, and establishing a closed-loop reporting system.

Read the Safety Advisory Notice: Safety at hospital helicopter landing sites

Read the Aviation Data and Analysis Report: Downwash incidents at helicopter landing sites

Publication Date
27/09/2023

Here is the safety advisory notice:



From pg 7 of the report:

Australia

The Civil Aviation Safety Authority (CASA) does not regulate the design or operation of HLSs if
they are not an integral element of an aerodrome certified under Part 139 of the Civil Aviation
Safety Regulations (CASR) 1998. As hospital HLSs are not located at Part 139 certified
aerodromes, CASA does not regulate their design or operation...

Still not sure why Popinjay's head crew feel the need to big note themselves in bogus media disengaged press releases?? However, all in all not a bad effort from the research boffins at Popinjay HQ...  

As a passing strange coincidence, I noted the following Aerossurance post on LinkedIn:

Aerossurance
27,092 followers
1w • Edited •

https://lnkd.in/deBjpdus #helicopter #heliport #airambulance #hems #downwash #flightsafety #aviationsafety

This was the Foreword:

Foreword

This guidebook is the result of a collaborative effort coordinated by the French Aviation Safety Network (RSAF). The RSAF is a national, multidisciplinary group of experts, including industry members, helicopter operators, and experts from DGAC – the French National Aviation Authority – and The French-Speaking Airports (UAF&FA). The guidebook targets primarily heliport and airport operators. However, it was written with all stakeholders and practitioners in mind, including non-aviation organizations operating heliports (e.g., local governments, hospitals, etc.), and each of them should find useful information that they can use to address safety issues in their field of operations as well as to learn about others’ concerns. It provides a state of the art on the helicopter downwash related hazards, as well as best practices on their mitigation in the field.

The document was developed based on a review of the literature available as of November 2022. Resources include documents from the aviation industry (manufacturers and operators) and institutions (e.g., ONERA, FAA, DSAC), as well as lessons learned from past accidents and incidents with safety reports and analyses from BEA, ECCAIRS, operators, and OEMs. It is important to remember that this guidebook is not an advisory circular or a guidance material for certification purpose, nor an alternative mean of compliance (AltMOC). It does not supersede the position of the Authority in charge of issuing required approvals, regarding operations or training.

DGAC DSAC Safety Guidebook

The link to the English version of the document is provided here:
Modèle de rapport DGAC/DSAC (ecologie.gouv.fr)

(Plus Aerosurrance included this media video link: https://abc7.com/rancho-cucamonga-childr.../11812717/ )

How come there was no collaboration with Australian authorities, including CASA and the ATSB, or reference to the recently released AD-2022-01 and the associated SAN? Surely the ATSB report has been filed with ICAO and the associated occurrences are subsequently listed in the ECCAIRS database??

Also of passing strange coincidence, yesterday the AAIB reported on social media the release of a final report into a fatal accident at a hospital HLS:

AAIB
@aaibgovuk

The AAIB has published a report into a fatal accident involving a Sikorsky S-92A (G-MCGY) that occurred at Derriford Hospital, Plymouth, Devon on 4 March 2022.

Read the report here https://gov.uk/government/news/aaib-form...march-2022
#AviationSafety #HelicopterSafety

From the report:
 

AAIB Formal Report: Sikorsky S-92A (G-MCGY), Fatal accident, 4 March 2022

Several members of the public were subjected to high levels of downwash from the approach and landing of a search and rescue helicopter. One person suffered fatal injuries and another was seriously injured.

From: Air Accidents Investigation Branch
Published 2 November 2023



Summary
The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital, Plymouth, which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries and another was seriously injured.

Investigation findings
The investigation identified two causal factors for this accident:

The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the Helicopter Landing Site
Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around Derriford Hospital’s Helicopter Landing Site that was subject to high levels of downwash.
The following contributory factors were also identified:

1. The HLS at Derriford Hospital was designed and built to comply with the guidance available at that time, but that guidance did not adequately address the issue of helicopter downwash.

The hazard of helicopter downwash in the car parks adjacent to the HLS was not identified, and the risk of possible injury to uninvolved persons was not properly assessed.

A number of helicopter downwash complaints and incidents at Derriford Hospital were recorded and investigated. Action was taken in each case to address the causes identified, but the investigations did not identify the need to manage the downwash hazard in Car Park B, so the actions taken were not effective in preventing future occurrences.

Prior to this accident, nobody at Derriford Hospital that the AAIB spoke to was aware of the existence of Civil Aviation Publication (CAP) 1264, which includes additional guidance on downwash and was published after the HLS at Derriford Hospital was constructed. The document was not retrospectively applicable to existing HLS.

The operator of G-MCGY was not fully aware of the Derriford Hospital HLS Response Team staff’s roles, responsibilities, and standard operating procedures.

The commander of G-MCGY believed that the car park surrounding the Derriford Hospital HLS would be secured by the hospital’s HLS Response Team staff, but the co‑pilot believed these staff were only responsible for securing the HLS.

The Derriford Hospital staff responsible for the management of the HLS only considered the risk of downwash causing harm to members of the public within the boundary of the HLS and all the mitigations focused on limiting access to this space

The Derriford Hospital staff responsible for the management of the HLS had insufficient knowledge about helicopter operations to safely manage the downwash risk around the site.

The HLS safety management processes at Derriford Hospital did not result in effective interventions to address the downwash hazard to people immediately outside the HLS.

HLS safety management processes at Derriford Hospital did not identify that the mitigations for the downwash hazard were not working well enough to provide adequate control of the risk from downwash.

Communication between helicopter operators and Derriford Hospital was ineffective in ensuring that all the risks at the Derriford Hospital HLS were identified and appropriately managed.

Safety at hospital HLS throughout the UK requires effective information sharing and collaboration between HLS Site Keepers and helicopter operators but, at the time of the accident, there was no convenient mechanism for information sharing between them.

Safety action and recommendations
Following this accident, safety action was taken by the helicopter operator, Derriford Hospital and NHS England Estates to control and mitigate the risk. Additional action by Derriford Hospital and NHS England Estates to improve safety is either planned or in progress.

Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the Hospital Landing Site Keepers and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.

Chief Inspector’s statement

Crispin Orr, Chief Inspector of Air Accidents said:

“This was an unusual and distressing accident in which an aircraft undertaking a mission to save life, sadly also resulted in the death of an uninvolved person and serious injury to another, who were blown over by high levels of downwash from a landing helicopter.

“Our in-depth investigation revealed systemic safety issues around the design and operation of hospital helicopter landing sites which need to be addressed at a national level.  Helicopters used for search, rescue and emergency medical services play a vital role, but it is essential that the risks associated with helicopter downwash are understood and well-managed.

“The investigation has raised awareness of this issue and been a catalyst for important safety action, which has been taken to mitigate the immediate risk.  In addition, nine recommendations have been made in this report to help improve coordination between the aviation and NHS stakeholders, to ensure the protection of uninvolved persons from helicopter operations at hospital helicopter landing sites across the UK.”

Read the report

Read that whole report and weep...   Without fear nor favour IE independently written and formatted under the direction and in total compliance with ICAO Annex 13 - 

Plus there is even a reference to a ATSB October 2021 Occurrence Brief: https://www.atsb.gov.au/publications/occ...b-2021-028

1.18.3.1 Australian Transportation Safety Board (ATSB) Investigation

In January 2022, the ATSB published an Aviation Occurrence Brief following
an accident where a pedestrian was seriously injured after being blown over
by a helicopter as it approached a hospital HLS. The pedestrian was reported
to have been walking about 50 m from the HLS, which was on an elevated
platform approximately 8 m above the road. The helicopter was an Augusta
Westland AW139, which has a maximum takeoff mass of 6,800 kg and a main
rotor diameter of approximately 14 m.

The ATSB said that they had received five reports involving ‘rotor wash’
(downwash) events at hospital HLSs since 2016, and three of them had
occurred at the same hospital. Before re-commencing operations at the HLS,
the operator and hospital took the following actions:

● They reduced the maximum number of helicopters allowed
on the HLS from two to one.
● They implemented pedestrian marshalling procedures for all
helicopter movements, so that operations only occur when no
pedestrians are within 30 m of the HLS.

The hospital engaged a consultant to review the design of the HLS, and the
ATSB publicised the following safety message in their report:

‘Helicopters produce significant main rotor downwash, especially
during hover taxi, take-off and while approaching to land. It is
important that the risk of downwash related injuries, either by direct
exposure or by being struck by loose items, be assessed prior to
using a helicopter landing site (HLS).

As pilots have limited ability to reduce rotor downwash during these
phases of flight, securing loose items in the vicinity of the HLS and
keeping people a safe distance away are the most effective ways
of preventing injury.’

Hmm...strange that, even though all three reports were apparently being worked on and composed on or around the same time, there appears to be no reference to the AD-2022-001 report or indeed the SAN (and visa versa)?? 

MTF...P2 

[Peetwo]

Popinjay to the rescue on Croc Wrangler R44 fatal? - 

Via PJ HQ:

ATSB releases King River crocodile egg collection helicopter accident investigation report



The Australian Transport Safety Bureau has released the final report from its transport safety investigation into an accident involving a Robinson R44 helicopter being used in the collection of crocodile eggs near the Northern Territory’s King River on 28 February 2022.

The ATSB investigation determined that the helicopter’s engine stopped in flight, probably due to fuel exhaustion. During the subsequent autorotation emergency forced landing procedure, the pilot released the hooks and sling line carrying an egg collector beneath the helicopter.

The egg collector was released above a height that would likely be survivable, the investigation found. And with insufficient main rotor energy to cushion the landing, the helicopter collided with the ground, and the pilot was seriously injured.

“Based on an analysis of fuel samples and other evidence, the ATSB investigation found that the helicopter was likely not refuelled at a fuel depot about three quarters of the way between Darwin and the crocodile egg collecting area, and that the pilot did not identify the reducing fuel state before the helicopter’s engine stopped due to fuel exhaustion,” said ATSB Chief Commissioner Angus Mitchell.

“As such, this accident illustrates the importance of effective fuel management, which is especially critical when operating a helicopter where a fuel-related power loss offers few safe options.”

The investigation found that the operator was not using its safety management system to systematically identify and manage operational hazards.

“As a result, the operator did not adequately address the risks inherent in conducting human sling operations, such as carriage of the egg collector above a survivable fall height,” Mr Mitchell said.

“In addition, and although not assessed on the evidence as having been contributory to this accident, the operator's history of non-compliance with regulatory requirements, maintenance standards and accurate record keeping, increased the risk level for much of their aviation activities.”

At the regulator level, the egg collection was being conducted under an instrument issued to the operator by the Civil Aviation Safety Authority (CASA) that authorised the pilot to carry a sling person on a 100 foot line attached to the helicopter.

“The ATSB found that CASA did not have an effective process for assuring an authorisation – the instrument issued to the operator – would be unlikely to adversely affect safety,” Mr Mitchell said.

As a result, the ATSB could not find evidence that CASA delegates used the available structured risk management process to identify and assess risks; to ensure suitable mitigations were included as conditions of the instrument; and to assess the effects of changes on the overall risk.

This resulted in removal of the instrument’s mitigating conditions limiting the height, speed and exposure for the sling person, which permitted carriage of the egg collector above a likely-survivable fall height.

“At the operator and regulatory level, effective safety management processes that identify and safely manage hazards are vital to preventing future accidents,” Mr Mitchell said.

“The ATSB notes that the operator has voluntarily ceased commercial helicopter operations, and welcomes that CASA has revised its documented regulatory exemption process, which should assure an adequate level of safety is achieved and documented when approving regulatory exemptions.

“Ultimately, this tragic accident highlights how the actions and decisions of pilots, operators and the regulator can all have a significant influence on aviation safety.”

Read the final report: Fuel exhaustion and collision with terrain involving Robinson R44 II, VH-IDW, King River, Northern Territory on 28 February 2022

Publication Date: 22/11/2023

Have started reading through the 113 page marathon of a report and so far I have been simply gob smacked by the implications and inferences implied by what is a really poorly written Final Report - let's just say I can understand why Pip Spence and CO are very sensitive about this whole tragic & sordid occurrence...

Hint: The Final Report published safety issues IMO tell the real story behind this latest interagency top cover report:

CASA lack of effective process

Safety issue description

The Civil Aviation Safety Authority (CASA) did not have an effective process for assuring an authorisation would be unlikely to have an adverse effect on safety. As a result, CASA delegates did not use the available structured risk management process to identify and assess the risks, ensure appropriate and adequate mitigations were included as conditions of the approval, or assess the effects of changes on the overall risk.

Issue number: AO-2022-009-SI-01

Issue owner: Civil Aviation Safety Authority (CASA)

Transport function: Aviation: General aviation

Current issue status: Closed – Adequately addressed

Issue status justification:

If the revised process is conducted as documented, the safety issue should be addressed. - (Why no monitoring?)

Response by CASA


CASA did not accept the safety issue and contended that its process of risk assessment and decision-making in relation to the conduct of HEC operations in piston engine helicopters appropriately identified and mitigated the applicable risks as far as practicable. However, CASA acknowledged that its decision-making in relation to the issue of HEC approvals over time, and the applicable risk assessments could have been better documented. CASA also accepted that there was an absence of a structured and standardised approach to risk assessment and advised of the following proactive safety action.

Proactive safety action taken by CASA

Action number: AO-2022-009-PSA-191

Action organisation: The Civil Aviation Safety Authority

Action status: Closed

CASA implemented significant changes to its internal processes to ensure that the assessment and management of safety risks of new aviation activities (and associated approvals) were standardised in accordance with the CASA Risk Management Manual and that decision-making was appropriately documented. Additionally, CASA developed an ‘exemption protocol suite’ of documents, which detailed the principles, protocols and work instructions for CASA’s regulatory exemption process. CASA also completed and provided exemplar bowtie and aviation safety risk assessments using the structured process.

ATSB comment

The ATSB welcomes CASA’s revised documented regulatory exemption process. If the process is conducted as documented, including the use of a structured risk management method, this should assure an adequate level of safety is achieved and documented when approving regulatory exemptions.

Helibrook inadequate safety management

Safety issue description


Helibrook’s approved safety management system was not being used to systematically identify and manage operational hazards. As a result, risks associated with conducting human external cargo operations such as carriage of the egg collector above a survivable fall height were not adequately addressed.

Issue number: AO-2022-009-SI-02

Issue owner: HELIBROOK PTY LTD

Transport function:/b] Aviation: General aviation

[b]Current issue status: Closed – No longer relevant

Issue status justification: As Helibrook has ceased operation, the safety management system is no longer in use.

Response by Helibrook

Following this accident, Helibrook advised the ATSB that they had ceased operation. They further advised that their helicopter fleet was being sold and the chief executive officer/chief pilot was no longer involved with the operation.

ATSB comment

CASA confirmed that as Helibrook no longer had the required key personnel, it was considered to be suspended from operation. Under those circumstances, the operator’s safety management system was no longer in use. The identified safety issue was therefore closed as no longer relevant. - How convenient??

Incidentally the above safety issues (at this point in time) do not exist as advertised:

The initial public version of these safety issues and actions are provided separately on the ATSB website, to facilitate monitoring by interested parties. Where relevant, the safety issues and actions will be updated on the ATSB website as further information about safety action comes to hand.

More amateur hour, or intentional?

MTF...P2