[Peetwo]

TICK TOCK goes the ATSB and CASA topcover clock -

Drifting slightly "K" I want to firstly focus on this post from Lead Balloon off the UP thread dealing with RossAir cover-up report:

https://www.pprune.org/10772770-post127.html

What is that power for, if not to compel the provision of information and the answering of questions for the purposes of an investigation? You don’t “request”, you “require”. And you then prosecute those who fail to comply with the requirement to produce material and answer questions.


The ATSB was “unable” to make a determination about the circumstances under which the incorrect procedure was approved for use by the operator, because the ATSB failed to exercise powers that it has to obtain information about those circumstances.

There will some sophistry around words like “approval” and “acceptance” - a matter touched on in the report - but the bottom line is that the incorrect procedure got there ‘somehow’ and there should be records in CASA and knowledge in CASA about that ‘how’.

Astonishing.

And that is not the only aberration/disconnection contained within the ATSB topcover report but first, also off the UP, an extremely relevant quote from OA:   

Old Akro once again nails it on the UP -   

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

Old Akro

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

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

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

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

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

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

Although technically not totally correct ie 'pilots operating a periodic review..' the point that OA makes does go to some of the other 'organisational factor' aberrations/disconnections that appear to have been glossed over inside of the bollocks O&O'd ATSB report. - 

Let me begin...

Extract from page 49 of the report:

The self-recommendation made by the chief pilot on his training records was for CASA to assess him in checking other check pilots, that is, just the Cessna 441 fleet manager, rather than checking all line pilots. Following that recommendation, a CASA FOI (who was on the accident flight) observed the Cessna 441 check pilot’s OPC, which was conducted by the chief pilot in the right-hand seat.

The Cessna 441 fleet manager believed that this check gave the chief pilot approval to conduct the fleet manager’s OPCs from then on, in line with the recommendation made on the chief pilot’s training form. Although the chief pilot submitted his training records to CASA following successful completion of his check pilot training in May 2016, no formal application form for check pilot approval was submitted to CASA at that time, and no regulatory services task was raised by CASA. The June 2016 flight was processed as a regulatory services task as a check pilot OPC, with no CASA documentation to support the chief pilot’s approval as a check pilot in this capacity. Following the accident, CASA verified the chief pilot did not hold any formal check pilot approvals.


In January 2017, a regulatory services task was raised for the chief pilot to be assessed as an EMB 120 check pilot. As noted in the section titled CASA awareness of Rossair workload, another CASA FOI observed the chief pilot undergoing an OPC (as captain/in the left seat), and made comments about his performance and CASA needing to observe his personal proficiency again before considering any check pilot privileges. Some of the operator’s personnel and staff within CASA interviewed by the ATSB recalled that CASA had observed the chief pilot again in the EMB 120 simulator, and they were under the impression that the chief pilot’s check pilot approval for the EMB 120 had progressed. However, CASA advised that no further observations of the chief pilot’s flying performance had been undertaken prior to the day of the accident and as of May 2017 the assessment for the EMB 120 check pilot approval had not been completed.



On 2 May 2017, the chief pilot sent an email to CASA noting that the Cessna 441 fleet manager’s loss of a medical certificate presented an ongoing challenge. He noted that the contractor Cessna 441 check pilot, who had recently conducted two checks on two of operator’s Cessna 441 pilots with CASA approval, would be conducting checks on behalf of the operator in the future. However, the chief pilot requested that he would like to conduct an OPC and line check on the contractor check pilot to induct him into the operator. Alternatively, he requested approval to conduct OPCs on another experienced Cessna 441 pilot. The chief pilot noted that he had been undergoing training as a backup to the fleet manager, and had conducted the fleet manager’s OPC in June 2016 under CASA observation. He also noted that he had since gained further experience on the Cessna 441 and had observed the fleet manager conduct other checks on the operator’s pilots.



On 4 May 2017, CASA responded to the chief pilot, and advised that it could arrange for an FOI to observe him conducting another OPC which, if successful, meant that it could issue him with an approval to conduct OPCs and line checks. CASA subsequently varied the EMB 120 check pilot task to become a Cessna 441 check pilot task. No formal application form was received (as requested by CASA), and therefore the normal pre-flight assessment verification process, as per the CASA AOC handbook, was not recorded as having been conducted.


In subsequent correspondence, the inductee pilot was nominated by the chief pilot as the person he would conduct the OPC on. The flight was to be observed by the CASA FOI who was a Cessna 441 specialist and had previously observed the chief pilot during the June 2016 flight. CASA personnel advised the ATSB that, following the chief pilot’s request on 2 May 2017, they had discussed the request among themselves (including the CMT manager) in the Adelaide office. They believe they had considered all the risk factors involved with the proposed flight, and had sufficient mitigators in place. However, there was no written record of these considerations.

Now note the following from the CASA RSR - VH-XMJ - REDACTED (28.10.19):
(Note that where a | is indicated in the timeline(s) denotes a redaction of the identity of the CASA FOI)

A review of the Check Pilot training records(5) for Martin Scott indicates he completed the training
in Part C of the operations manual, by completing the activities listed below:

• 4 April 2016 C441 2.8 Hrs by |
• 8 April 2016 C441 2.5 Hrs by|
• 20 April 2016 observing only
• 21 April 2016 observing only
• 22 April 2016 observing only
• 30 May 2016 C441 2.6 Hrs by |

Martin Scott provided the below documentation (which was forwarded to CASA) as certification
of completing the specified Check Pilot training:

• 15 April 2016 C441 OPC (LHS) 1.9 Hrs by|
• 30 May 2016 C441 OPC (RHS) 1.4 Hrs by |
• 30 May 2016 C441 Line Check Assessment 2.6 Hrs by|
• 30 May 2016 C441 Training syllabus check form recommendation

The Check Pilot training described in the manual was concluded 12 months prior to the
assessment by CASA (accident flight). Evidence was gained that a single refamiliarization
flight took place the week prior to the assessment. The practical functions that would have
been authorised by the CAO 82.0 Check Pilot approval are reasonably comparable to those of
a CASR Part 61 Flight Examiner Rating holder and the holder of a CASR Part 61 multi-engine
class (aeroplane) training endorsement. 

The timeline(s) above were from a CASA internal document (ie the RSR). Therefore one must assume that this was the official recollection/version of events from the applicable FOIs from the SA CASA regional office. Personally I would like to see the log book entries from all three accident pilots and also the former C441 Fleet manager. Especially when you consider the Fleet manager's interpretation (underlined above) and the fact that there would appear to be a 12 month disconnection between the Chief Pilot completing the required CASA outlined C441 training syllabus and then completing his check pilot approval assessment flight?        

MTF...P2 

[Peetwo]

The D&D: On Miniscule Stooges, FARPs, Iron Rings; White Hats and RRATs?? 

Trying desperately to place some DASHES between some intriguing DOTS in the current malaise besetting our long suffering, regulatory embuggered aviation sector -   



To begin with the dots: Q/ How is it remotely possible that after 9 months the search for the next DAS/CEO of CASA is still yet to be finalised and announced?  (Refer to the UP thread titled The next CASA CEO/DAS for the latest scuttlebutt) 

Lead Balloon

We’re all ears, Jake: Why hasn’t the DPM appointed a new CEO of CASA, despite 5 years’ notice that it had to be done?  

Next note the following extract from the 15 December 2020 edition of the Infrastructure Magazine: 

Mr McCormack also announced the establishment of the Future of Aviation Reference Panel, to be chaired by Professor Patrick Murray, to consult the aviation industry on the recently released Issues Paper on the Future of Australia’s Aviation Sector.


Professor Murray, Chair of the Aviation Safety Advisory Panel at the Civil Aviation Safety Authority and Professor of Aviation and Logistics at the University of Southern Queensland, will be joined by expert panel members Adrianne Fleming OAM, Andrew Drysdale and Shannon O’Hara.

“Each member brings expert and unique perspectives on various sectors of the aviation industry,” Mr McCormack said.

“The panel will assist the government in its ongoing support of the aviation sector as it carefully recovers from the pandemic and ensure we continue to have a safe, secure and efficient industry for Australia’s future.

“Managing the challenges to aviation resulting from the COVID-19 pandemic will require industry, regulators, governments and the community to work together. 

“I thank the aviation industry for their constructive engagement on the Future of Aviation Issues Paper and subsequent consultative workshops to date and I look forward to announcing the Government’s Five Year Plan for Aviation in the New Year.”

Further information on the Government’s COVID-19 support for aviation, the Future of Aviation Reference Panel and the forthcoming Five Year Plan for Aviation can be found at www.infrastructure.gov.au/aviation/future/index.aspx.

And from the 2018-19 CASA AR: 

The Aviation Safety Advisory Panel (ASAP), which was established in 2017 by the Director of Aviation Safety, has continued to mature into CASA’s primary, high-level engagement mechanism. During 2018–19, the ASAP established 19 technical working groups to provide expert technical advice on a range of matters, including fatigue rules, dangerous goods, remotely piloted aircraft systems, airworthiness, and the flight operations suite of regulations. This has allowed CASA to establish regulations which are fit for purpose and supported by industry. The ASAP has predominantly industry membership and Honorary Professor Patrick Murray, University of Southern Queensland, is the ASAP’s independent Chair.  

From LINKEDIN: 

PM link - 

Head of Flight Operations and Training

Company Name Aviation Australia
Dates Employed Feb 2015 – Present
Employment Duration 6 yrs 1 mo
Location Brisbane, Australia

CASA post-holder (Head of Operations) for Aviation Australia Part 141 & Part 142.
Aviation Australia has pioneered the development of multi - crew (MCC) pilot training in Australia.

Ref: Adrianne Fleming OAM

Q/ How is it not a conflict of interest that both Murray and Fleming feature in both the ASAP and the FARP? Independent? Yeah RIGHT - 

I also have it on good authority that Prof Pat has a long and infamous history of being nothing more than a miniscule stooge put in place to provide obfuscation and preordained (Iron Ring endorsed) top-cover outcomes and protection for the Ministerial rump - 

This brings me to the next couple of dots with a further reference to the PM CV:

Group General Manager

Company Name Civil Aviation Safety Authority
Dates Employed 2005 – 2008
Employment Duration 3 yrs
Head of Air Transport Operations Group

Apparently (so the rumour goes) Byron was fully aware that PM was a 'wrong un' and quietly handed him his marching orders in 2008. Perhaps if PM were able to hang on for a further 6 months he may well have been a perfect acolyte in the McCormick regime and by now may have been firmly entrenched within the ASC/Iron Ring ranks?

Which brings me to the next DOT because there was another former CASA executive manager who was making his mark in 2008:

MQ CV: Deputy CEO, Operations.

Company Name CASA
Dates Employed Dec 2007 – Jan 2010
Employment Duration 2 yrs 2 mos
Location Brisbane Area, Australia canberra

Responsible for all heavy air transport category\general aviation regulatory operations and enforcement action.

Executive strategy and penultimate delegate of the Government Act of 1988.

Senate Committee witness, Audit & Risk Committee Member, Chairman Accident Investigation Report Review Board.

Aviation Safety Forum Member.

(P2 comment - A point of interest was that in 2008 MQ made an informative presentation to the ANZSASI (ASASI) regional seminar - read and absorb for future DOTs related to the ASC and sector risk profiles): reference - Challenges in Regulation Presented by Mick Quinn

Now think on this P377 UP post - 

More possibilities......Greg Hood?



Mick’s LinkedIn profile now shows him as ‘freelancer’, so I was correct about him resigning. However I’m not so sure anymore that it is he who will receive the CEO DAS crown however. He can be a naughty boy at times. Just keep the keys to the liquor cabinet away from him (and ban him from the photocopier room)


Interestingly, Mr Carmody also has his profile updated to ‘freelancer’ on LinkedIn. No doubt he will receive some aviation consultative work from the Government. Snouts in the trough - it’s the gift that keeps on giving. Perhaps he is also looking for work as an obsfucator, serial bullshitter and he can offer consultative advice about how to spend 30+ years sucking off the taxpayer teat? Mind you, with those giant ears of his (gives Daniel Andrews a run for his money) he could be used to test aerodynamics in a wind tunnel. His other strengths are being a good footstool.

Finally, what’s the deal with Mr Hood from the ATSB? His position has been advertised also. He too is a former CASA Deputy DAS. Has he resigned from the ATSB or is his contract up for renewal and the Government is following the rules of transparency and putting the role out there for any qualified candidate to apply? He does tick the Governments LGBTQ box. Perhaps party boy Greg has his sights set on Montreal and a stint with ICAO? Note to Greg: they are a bunch of dullards over there and they won’t tolerate any shenanigans. Strictly sports jackets and iced tea. No laughing permitted.

A long shot could always be the return of The Screaming Skull or Bruce Byron??

Hmm...much, much...MTF! - P2 

[Kharon]

Poker - with a marked deck; anyone?

Or, Russian Roulette with five loaded chambers; or, rolling loaded dice; a hiding to nothing is the inevitable result. P2's dots clearly define the rigged game. The art of a rigged game is to convince the 'mark' that there is a chance of winning. Great effort goes into presenting a honest, straight game. Should the Patsy suspect that this is a con game, then that effort and the profit disappears like smoke in the breeze. This where the 'dots' lead us.

McCormack's merry band of shysters are busily setting the stage; there's been too much ruckus to ignore completely; so. It has to look good. It must convince the mug punter that there is a sporting chance of a win. A long con game, rather than the usual blatant daylight robbery. 

The 'Dot's' only beg answers to two questions; who has the power to make the changes? And; to whom will the minister listen?

At the end of the shift, despite the hundreds of factual, articulate submissions, to countless Senate Inquiry, the millions spent, the clear distress the aviation industry is in, the window dressing crew will win. The noisy rabble barking at the gates can be ignored as, on paper, there has been a 'consultative' process, two hand picked ministerial 'expert' panels and the sage advice of the three 'safety' agencies to rely on. With his hand on his miserable black heart; this putrid minister can say - “we consulted, listened and have decided the best course is". Etc. (Fill in the obvious answer). One last question:- - can you imagine, in your wildest dreams, the WWWW from Wagga admitting “It's a bloody expensive shambles and I intend to make extensive, serious changes to the way we, in Australia, manage our aviation industry”.

No – didn't think so. All the dots lead to the ministerial office – if you want change start there. Find someone who can see the savings and efficiencies of world standards across the aviation spectrum; someone who will clean out the self serving advice which defends the indefensible. For that is what we have when we join the dots; lots of folk scurrying about, try to convince the punters that this pantomime is the real deal. Smoke, mirrors and bullshit will not regenerate aviation commerce or improve safety.

Toot – toot...

[Peetwo]

AMSA suspends ops on new Manly ferries - 

(CAUTION: Thread drift alert -  )

Courtesy MattO, via the SMH:

Fears problem-plagued Manly ferries will be out of service for weeks

Matt O'Sullivan
October 7, 2022 — 1.45pm

The NSW government’s three problem-plagued Manly ferries are under orders not to carry passengers until an exhaustive process to fix steering faults is completed, sparking concern they will be out of service for many more weeks.

The three new Emerald-class vessels have been out of operation since September 26, after two of them – the Fairlight and the Clontarf – suffered steering failures over two consecutive days.


The three new Manly ferries tied up at the Balmain Shipyards.CREDIT:OSCAR COLMAN

The government has now confirmed that the Australian Maritime Safety Authority has issued directions preventing the three second-generation ferries from carrying passengers until steering faults are fixed and verified.

It has raised fears from ferry watchers that the three catamarans will be out for weeks – if not months – because of the exhaustive process required to meet the safety authority’s standards before they can be returned to service on the popular F1 Circular Quay-Manly route.

Services on the route have been cut from a ferry every 20 minutes to 30-minute frequencies on weekdays because of the withdrawal of the Emerald-class ferries.

Labor’s acting transport spokesman John Graham said the three overseas-built ferries could be out of action for weeks, arguing commuters were paying the price for the government’s procurement policies.


The Clontarf, which is tied up at the Bailmain Shipyard, suffered a steering failure late last month.CREDIT:OSCAR COLMAN

“These serious safety issues are leading to delays. Passengers are seeing delays of at least 10 minutes to catch a Manly ferry, with no end in sight,” he said.

Transport for NSW and French company Transdev, which operates the government-owned ferry fleet in Sydney, have repeatedly declined to say when they expect the three Emerald-class vessels will return to full service.

Transdev said the investigation into the steering problems was continuing, and technical assessments were nearing completion.

“Our priority remains fixing the steering issues and returning the vessels to service as quickly as possible,” it said.

Action for Public Transport spokesman Graeme Taylor said the directive from the maritime safety authority would require a proper diagnosis and fix of the ferries, which remain tied up at the Balmain Shipyard.

“They could be out for months. It is going to be a complicated process,” he said.

Transport for NSW has until early next week to provide Transport Minister David Elliott with a review he ordered into the cause of the steering failure on the Fairlight, and whether it was linked to that on the Clontarf.

The three new catamaran ferries are at the centre of a fierce debate over whether they can handle large swells as well as the larger Freshwater vessels they are designed to replace on the Manly-Circular Quay route. The government plans to retire two of the four Freshwater ferries.

Northern Beaches councillor Candy Bingham, who has campaigned to retain the Freshwater ferries, said it was clear that the second-generation Emerald-class ferries were unsuitable for the route.

“There are too many issues and now the service is unreliable,” she said.

 
Here is a link for the OTSI Pemulwuy LOC final report: https://www.parliament.nsw.gov.au/tp/fil...arbour.pdf

AMSA

4.6 Review incident reporting, classification and follow up procedures to ensure
incidents are responded to consistent with their level of risk to safety.

Next (via FB) from the Master of the Narrabeen:

Chris Cowper

Looks like French owned Transdev are still having problems with their Chinese built Gen II Emeralds. On Tuesday (15th) "Fairlight", as she was on her final approach to Manly Wharf, had a steering failure. Her highly skilled and experienced Crew were able to engage  Back-up Steering Control and berth her without damage or injury.

I'm told by former Crew Mates, Gen II Emeralds have had several other Steering Failures in recent weeks.
"Balmoral" has had several Steering failures this week.

As I write, I received a message, she has had another Steering failure.

In the past, Transdev Management have tried to convince me a Steering Toggle failure isn't a Steering failure. This is a stupid argument. Made by stupid people.

If the Master of a Vessel experiences a loss of control, through the failure of any equipment, it is a failure of the system.

Berthing a 35 metre, 400 passenger Ferry, is a Safety Critical operation.

Transdev's Masters must be able to have full confidence in all safety systems on their Vessels.
Unfortunately,  history may be repeating itself.

During 2020, Gen I Emeralds suffered several catastrophic steering failures. Probably more than 6 in total.

I was  Master of "Narrabeen" on 2nd July 2021 and witnessed "Pemulwuy"  have a catastrophic Steering failure at high speed.

When, after 12 days, Transdev had not carried out investigations to find the cause of these failures, I reported this incident to AMSA. (Australian Maritime Safely Authority) As a result, OTSI (Office of Transport Safety Investigations) conducted an investigation. All 6 Gen I Emeralds had to have modifications made to their Steering systems.

The OTSI report is on their Website.

For my troubles, I was suspended from duty for 9 weeks.

What are AMSA & OTSI doing about the recent Gen II Steering failures?

Has Transdev reported these incidents to AMSA, OTSI & Sydney Ports?

What is Transdev doing to ensure Gen II Emeralds don't have more Steering failures?

 

Hmm...so what has happened to prompt AMSA into grounding these vessels? 

It would appear that OTSI (the NSW [supposedly independent] Transport Safety Investigator) has racked the cue (since the Pemulwuy OTSI Final Report) on the Emerald class (Gen I & II) requiring further safety risk mitigation with uncommanded steering events - err why..

MTF...P2 

[Kharon]

Shall I compare thee to a- -  JUMBO JET?

Why not? 400 SOB, taxi speed 30 to 40 KpH, tight area to manoeuvre a large vessel in, pointed at a crowded terminal or joining a busy taxiway. Hardly the place to have one isolated 'steering' failure is it? Let alone 'multiple' events.... Yet Sydney's (gate way to Australia sporting an internationally recognised harbour and bridge) harbour and river ferry services, operated by a French company, running the new, cheap Chinese ferries can have multiple failures of the same system in a busy harbour with hundreds of folk waiting on the dockside and there's barely a ripple of public interest. Had these incidents involved aircraft there would be more than one journo banging the safety drum and a bloody sight more heavy duty 'safety' outfits involved than the gutless NSW OTSI.

Hell's bells - NSW spent more time and much more money agonising over which 'flag' to fly over the iconic bridge than it did on investigating the obvious potential for what could result in a very serious, costly accident, in both human and fiscal terms.

Consider this:- “In the past, Transdev Management have tried to convince me a Steering Toggle failure isn't a Steering failure”. - Chris Cowper, Ferry Master.

Can you imagine a Qantas Captain (or any Captain) swallowing that more than once? Point is, that for whatever reason, instead of turning left at Albuquerque; the 'ship' took an un commanded path; unacceptable. Once in 10,000 hours – yes; maybe, but multiple instances of the same system failure, over a short period of time?  – WTD?.....

Chris Cowper, Ferry Master. - “When, after 12 days, Transdev had not carried out investigations to find the cause of these failures, I reported this incident to AMSA. (Australian Maritime Safely Authority) As a result, OTSI (Office of Transport Safety Investigations) conducted an investigation. All 6 Gen I Emeralds had to have modifications made to their Steering systems."

That begs the question though, don't it?  Just who's interests are the priority?– Certainly not the thousands of passengers who take a boat trip every day, rain , hail or shine, despite the rough passage across the harbour heads. Their 'safety' should be the one and only top priority. To coin an old adage, if you think 'safety' is expensive; try having an accident. The blessed legal bills alone would make a stone idol weep, not to mention the political fall out. That, IMO is irresponsible 'governance' – writ large across the entire spectrum. Not too much imagination required from those who understand the way in which the upper middle layers work – the word from the top filters down to the comfortably ensconced - “put a lid on this and play it down” - “right away” says the mid level nameless chump, conscious only of the rice bowl and protection thereof.

The Cowper story is an excellent example of abrogation and deception where the elected pass the buck down stream, to a place far removed from their office to the un-elected. Millions spent on a pointless Flag waving, publicity stunt and a legitimate safety concern from the Masters of large ships with 400 lives on board can be shuffled down the ranks and played away to a 'nothing to see here – move along' event. Its not good enough is it?  Nowhere near. 

Aye well:- “hush, hush, Whisper who dares; the government is saying it's prayers.” No matter:- Bravo Captain Cowper; well done Matt  O'Sullivan, and thank you AMSA (on behalf of the men, women and children of Sydney siders ferry using fraternity).

(Sotto voce) - Toot – toot.

[Peetwo]

Dots-n-dashes on DFO approval process investigation??

Doing my usual weekly trolling of the severely convoluted, user unfriendly Popinjay ATSB website for updates - I happened to refer to the AI-2018-010: Aerodrome design changes and the Bulla Road Precinct development at Essendon Fields Airport, Melbourne, Victoria. Despite the promise of...

"..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..." 

...there is still no updates?? - Yet another broken promise by Popinjay..

However as a sidebar, I did happen to come across an interesting link to a AusALPA submission to the Essendon Fields Airport operator in the lead up to the 2019 pdMP: https://auntypru.com/wp-content/uploads/...tation.pdf

---

---

---

Since that submission the 2019 pdMP has been deferred twice with the latest update referring to the miniscule asking for more information: ref - https://ef.com.au/about-us/master-plan/

A review of the current 2013 Master Plan is underway, as required by the Airports Act 1996.

In 2019 Essendon Airport Pty Ltd (EAPL) advertised a preliminary version of its draft Master Plan (dMP) 2019 which was available for public consultation from April to July 2019. The EAPL dMP had been prepared based on information at the time that Melbourne Airport’s proposed third runway would be oriented east-west.

In November 2019 Melbourne Airport announced that their third runway would be built in a north-south orientation, and in response to uncertainties about how these changed plans might impact air traffic movements at Essendon Fields, the EAPL dMP 2019 was subsequently withdrawn, and an extension granted by the Minister.

Melbourne Airport’s draft Master Plan 2022 has been approved. However, the Third Runway Major Development Plan (M3R MDP) is still being evaluated and is yet to be determined by the Minister for Infrastructure, Transport and Regional Development, The Hon. Catherine King.

EAPL recently wrote to the Minister requesting a further extension of time to submit the EAPL dMP, noting the continued uncertainty regarding how a north-south oriented third runway at Melbourne will impact users of Essendon Fields Airport and the surrounding community.

On this basis, a further extension of time until 31 January 2025 has been granted by the Minister, which will allow EAPL to update all plans, including the Australian Noise Exposure Forecast, and consult with stakeholders in consideration of the M3R MDP once it has been determined by the Minister.

The decision by the Minister to grant this further extension is is an important and fair outcome for the community because the updated EAPL dMP 2025 will be based on the most up-to-date information and be more accurate in its forecasts. We are grateful for the continued collaborative and constructive approach taken by the Minister and key personnel at DITRDC in delivering this outcome for the community.

We expect that public consultation for EAPL’s revised dMP 2024 will commence in Q3 2024. In the meantime, the 2013 Master Plan remains in effect.

In the context of the AusALPA submission, I note that there was a reference to a 2008, 2 part ATSB research report: https://auntypru.com/wp-content/uploads/2023/05/665.pdf & https://auntypru.com/wp-content/uploads/...rsions.pdf 

In light of the now five year (consistently delayed) AI-2018-010 investigation, the above may help to explain (along with an outstanding Coroner's inquest and Texan Lawyers) why it is that this investigation seems to be stuck in a constant time-warp loop?? - IE They don't want to have to demolish the DFO! 

MTF...P2 

[Peetwo]

Thirtieth anniversary of Monarch Accident -   

Tomorrow mark's the 30th anniversary of the tragic Monarch accident. The BASI final report is still recognised internationally as a benchmark and first major AAI that directly used the James Reason accident causation model: Piper PA31-350 Chieftain VH-NDU Young, NSW 11 June 1993

Read from page 62 the Safety Actions and Recommendations, the pushback from the CAA is very obvious and perhaps reflects where the antagonism between the Federal regulator and investigator first began...  

Again much MTF...P2 

[Peetwo]

P86 international historical AAI relevance of Monarch disaster?? -

At a recent BRB shindig discussion went to the 30th anniversary of the Monarch Airlines crash at Young NSW and it's significance in the history of ICAO Annex 13 international aviation accident investigation and how Oz AAI standards have decayed becoming the subject of international ridicule ever since.

One of the participants of that BRB get together was P86 and the Monarch discussion inspired him to follow up with some contextual notes that he sent through via the BRB emails...

As you’ll no doubt recall, this was a landmark report in Australia (and worldwide in the AAI field). It’s worth reading it all again, particularly now with the benefit of hindsight. Also, the straight, simple language doesn’t miss the message of the critical nature of all the entities roles in the system.

Not a bad first attempt for a new approach, 30 years ago. Interesting to note how the language has changed over the years.



https://www.atsb.gov.au/publications/inv...r199301743

To briefly put this analytical approach into context, the model used was developed by Prof James Reason, University of Manchester during the 1980’s. Reason had worked with other academics specialising in cognitive engineering, nuclear engineering and organisational psychology. His research had included analysis of the: Bhopal chemical tragedy, Chernobyl nuclear disaster, Three Mile Island nuclear disaster, Piper Alpha oil rig fire, Kings Cross Rail fire, Exxon Valdez oil spill, Herald of Free Enterprise ferry disaster and Space Shuttle Challenger accident.

It was the first aviation accident report in Australia based on Reason's model and one of the first in the world. ICAO were particularly interested in the the report and supported its analytical adoption for accidents with broad organisational influence. BASI used this approach the following year with the Seaview accident. Rob Lee (HF expert and Director BASI) continued liaising with other academics, including Prof. Patrick Hudson and Jop Groeneweg, PhD (Shell Tripod Delta author/HF Leiden university) and Dan Maurino (ICAO) in developing the model for continuing practical application into the aviation industry. Lee (ex-BASI) was an accredited representative (ICAO Annex 13, 5.23) to the Bahraini, Taiwanese governments for the GF-072 (Gulf CFIT) 2000 and SQ006 (Runway-Equipment collision).
https://bea.aero/docspa/2000/a40-ek00082...0823a.html
https://www.ttsb.gov.tw/media/4252/sq006...ummary.pdf
It’s worth noting that Lee was a HF investigator in two RAAF investigations (Macchi and F-111) and the first BASI HF investigator in 1983, prior to becoming Director in 1989. Compare this background to the current department executive.

Although being widely adopted worldwide, the model had some criticism for being too linear, simplistic and shifting blame onto organisations (in a just culture/no-blame environment!). Reason himself was critical of the over use of the model and highlighted that it wasn’t a tool for every scenario, however it provided logical analysis of how organisational activities influence outcomes in complex, high reliability operations. Some suggest it is currently being used to review aspects of organisations that have no direct, or indirect influence on the accident - like an audit tool for accident investigators to highlight non-related deficiencies as systemic or cultural issues. 

I think the Coroner’s view of a recent report says it all.




Reference: https://www.abc.net.au/news/2022-08-25/c.../101370152

The organisational approach used in the Monarch accident requires a mature industry to achieve continual improvement. This includes; accident investigators, companies, regulators, unions and politicians….. You’d be hard pressed trying to prove we have that today. I could draw comparisons from this effort 30 years ago till now, but it would be like writing an Annex 13 report in-itself!  There’s a lot here to unpack.

   
Normally big on significant historical Australian aviation accident investigations, the ATSB and CASA (aided and abetted by the MSM) strangely did not acknowledge the 30th Anniversary of Monarch?? However there was two small regional media outlets that did - well done the-riotact.com and 'About Regional' ...  :

How the tragedy of Young's Monarch plane crash paved the way for safer skies

11 June 2023 | Edwina Mason



Police officers at the scene of the Monarch Airlines crash near Young 30 years ago. Image: National Library of Australia.

---

Thirty years ago on this day – June 11 – a small 10-seater Piper PA31-350 Navajo Chieftain attempted several landings from the south of Young’s airport around 7:10 pm.

Travelling from Sydney – the Monarch Airlines flight OB301 flight carried seven occupants, including the two pilots.

It was a bleak moonless night, so characteristic of June in the NSW South West Slopes, one where low cloud and darkness conspired with blowy, icy conditions and undulating tree-scattered terrain to challenge any pilot flying into the small aerodrome.

Two flights were scheduled for arrival. Waiting families and friends huddled in the small stark aerodrome building.

From above, the only sign of life below was the light from that building and tarmac lights. From below, the unmistakable drone of an engine, flashing small wing lights as the craft circled the airport.

One aircraft landed that night. The other didn’t.

Searching beyond the rain-shrouded landing strip on a hill, a light was sighted. It remained stationary.

That light was a fireball; the result of Monarch Airlines flight crashing into a hill on approach, first hitting three successive trees, leaving what remained – the fuselage – to land on a boulder, split in two, one part landing on the plane’s already severed right wing before incinerating in a fire fed from an estimated 366 litres of aviation fuel.

Everybody on board died as a result of the impact and fire. One not immediately.

One survivor had been thrown from the plane. She was discovered near the wreckage around 8 pm. The following morning in Sydney’s Camperdown Children’s Hospital she succumbed to her injuries.

She was one of three Pymble Ladies College students – Allanda Clark, 16, Jane Gay, 14, and Prudence Papworth, 14, – homeward bound from boarding school on a flight that included popular Cootamundra councillor Stephen Ward, 42, and Queens Counsel William (Bill) Caldwell, 45, whose farming family have long been connected with the district.

Also killed were the pilot Wayne Gorham, 42 and co-pilot Brynley David Baker, 24.

Today a bronze plaque fixed to a granite rock atop that hill memorialises those seven killed. But the anguish is still lugged around in the hearts and memories of those whose recollections of that crash remain undimmed.

One of those people was John Sharpe.

Away with his wife celebrating their anniversary – he took an early morning call from a friend to see if he was still alive.

“I said “yes, why do you ask,” and the caller said the local radio was saying a politician was killed in that crash last night,” John told Region.

John had notched up nine years with the Nationals representing Gilmore which had been redistributed into Hume.

He’d grown up beside and overlooking Young airport – his sister and he with their parents on a historic property called “Clifton”. Also a pilot, he was a member of the Young Aero Club.

“So I knew that the airport runway in the surrounding territory pretty well, and I knew about that hill,” he said.

Bar the co-pilot, he also knew everybody on that flight.



Days after the crash, the MP who was also the federal shadow transport minister, stood at the site with an overpowering sense of responsibility in finding answers.

“Yes, it was personal – I knew most people on that flight and their families, I was standing on the burnt grass trying to work out, like everyone else, how this had happened”.

Time froze as news of the crash reverberated around the district – to this day, most recall with unmistakable clarity what they were doing when they heard.

“The feeling in the community at the time was obviously very overpowering because we’d lost six people from the local area. Many of them young kids, high school kids coming home for a long weekend,” he said.

“I made it my mission to pursue the reason why this crash had occurred.”

Thirteen months later, the Bureau of Air Safety Investigation’s (BASI) official report said the final uncommanded descent was merely a culminating factor. Weather and climate were implicated. The weather evident; the climate less visible but equally real: the priorities, assumptions and values under which the airline and its regulator operated.

Missing instruments, inadequate training and commercial priorities; the airline had been red flagged six weeks earlier but remained operational.

The day following the crash, John said, bizarrely, it continued flying into Young.

“What I couldn’t work out was how this could occur right under the very nose of the then Civil Aviation Authority (CAA) when they were literally almost next door to Monarch’s offices and building and all these things were going on right under their nose.”

“As somebody who’s been a pilot, you understand these things moderately – you sort of say to yourself this surely couldn’t have happened if the safety regulator was doing its job.”

Also buried beneath Monarch’s wreckage, rattling revelations about national airline safety regulation, showing systemic failures in the CAA’s safety surveillance operations.

“People were coming to me with all sorts of stories about what was going on and how the rules were being bypassed and airlines were operating unsafely,” John said.

“The more I learned, the more incensed I became, and the more motivated to make changes. I became emboldened,” John said, “because when you make these claims publicly, you get criticized by all sorts of people – they really hop into you and they call you all sorts of things, but you get to get involved because you think ‘you can say all that, but guess what?'”

“People die when you get it wrong. And you’ve got it wrong, and people are dead. And to me, that’s completely unacceptable. And we can’t let it happen again. And I’ll do my best to make sure it doesn’t.”

One CAA whistleblower would bleed official files concealed in rolled-up copies of The Canberra Times to John’s chief of staff, also carrying a rolled-up copy of the paper, at Woden Bus Interchange.

With this, John had the ammunition necessary to campaign against the CAA with parliament as his platform.

On 4 May 1994, he warned parliament of an airline operating so dangerously it was putting people’s lives at risk if it continued to fly.

John said it gave him no satisfaction that those concerns were most sadly proven correct by the Seaview crash in October that year.

By July 1995, the CAA had been split into an airspace management organisation called Airservices Australia, and an aviation safety authority, the Civil Aviation Safety Authority (CASA).

In 1996 John became federal transport and regional development minister, initiating a complete rewrite of the CASA’s regulations with robust powers still enforced today.

“I’d like to think we’ve reduced the risk of flying, reduced the accidents,” he said.

William Caldwell’s wife Hilary became a founding member of the Airline Passenger Safety Association, was a consumer representative on CASA’s Program Advisory Panel (PAP) and, in 2000, was appointed to a new consultative body, the Aviation Safety Forum, formed to provide strategic advice to the Civil Aviation Safety Authority (CASA).

“I wanted her there to oversight operations so at least they have somebody who knows what it’s like when you get it wrong,” John said.

“Monarch was a tragedy that should never have happened, as was Seaview and I look back and I think, because of all that things are safer, we’ve fixed a lot of those problems and the effort was worth it,” John said, “nothing will bring those people back you realise, nothing’s ever going to bring them back”.

Original Article published by Edwina Mason on About Regional.

    
MTF...P2 

[Peetwo]

Popinjay v Su_Spence; closing safety loops?? - Let's do the timewarp again!

Remember this?

That was from Budget Estimates nearly 12 years ago and signifies the start of Senator Fawcett's concern ('closing safety loops') for a lack of proactive action by Government departments and agencies (responsible for the oversight of the aviation industry and aviation safety) in response to safety recommendations addressed to them by both the ATSB and State Coroners.

The example he used came from a PAIN_Net document called 'Coronial analysis':





DF followed up his questioning of Murky Mrdak on 'closing safety loops' in the 2012 Supplementary Estimates, which ironically was held a week before the infamous (now forgotten) Senate AAI (PelAir) inquiry began:

FFWD 7 years to this Ferryman 'Closing the safety loop - Coroners, ATSB & CASA' thread post..

Safety Loop or Hangman’s noose?

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

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

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

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

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

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

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

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

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

Toot – toot.

And on the subject of ATSB issuing safety recommendations addressed to CASA, PAIN did an opinion piece in 2015 which included a statistical comparison to the 'Gold Standard' NTSB:







Now FFWD to last week, when Popinjay was attributed to yet another bollocks media release for the release of the final report into the AO-2022-016 systemic investigation:

Effective risk management of inadvertent entry into IMC relies on multiple layers of controls, ATSB Mt Disappointment investigation highlights

The ATSB investigation into an Airbus EC130 helicopter accident on Mount Disappointment highlights that the effective management of the risk of inadvertent entry into instrument meteorological conditions (IMC) relies on multiple layers of controls.

The helicopter was one of two EC130s, operated by Microflite, which had departed a helipad at Melbourne’s Batman Park bound for Ulupna in Victoria’s north, on 31 March 2022. The pilots of both helicopters were operating under the visual flight rules (VFR) – regulations that permit a pilot to operate an aircraft only in weather conditions clear enough to allow the pilot to see where the aircraft is going – but had planned and commenced a route for which instrument meteorological conditions were present.

The pilots continued the flight as conditions deteriorated until a rapid change of course was required to avoid entering cloud.

“During the attempted U-turn without visual cues the second helicopter developed a high rate of descent, resulting in the collision with terrain,” said ATSB Chief Commissioner Angus Mitchell.

“Unfortunately, the pilot had no instrument flying experience, and the helicopter was not equipped with any form of artificial stabilisation, albeit neither of which are required for VFR flying.”

All five occupants of the helicopter were fatally injured in the accident.

Mr Mitchell noted that whilst not required by regulations the helicopter operator had not incorporated several available risk controls for their day VFR pilots to mitigate against inadvertent entry into IMC.

“These risk controls may have included inadvertent IMC recovery training and basic instrument flying competency checks during operator proficiency checks.”

The operator had also not introduced an inadvertent IMC recovery procedure for their air transport operations, or a pre-flight risk assessment to trigger an escalation process for marginal weather conditions identified at the pre-flight planning stage.

The investigation report notes that the operator had identified poor weather conditions as a risk, but its management of that risk was limited to the mandated regulatory requirements, and it did not consider ways to enhance pilot recovery from an inadvertent IMC event.

The Civil Aviation Safety Regulations for rotorcraft air transport (Part 133) only require the risk of a VFR inadvertent IMC event to be managed through avoidance.

“While avoidance of inadvertent IMC is important, it is not always assured, and Part 133 does not address the risk of recovery from an inadvertent IMC entry event.”

Mr Mitchell said the ATSB encourages all pilots to develop the knowledge and skills required to manage the risk of inadvertent IMC.

“Decision-making in marginal weather conditions can be supported with the use of a pre-flight risk assessment tool,” he said.

At an organisational level, the risk of helicopter inadvertent IMC should be considered within the context of a company’s operations.

“The effective management of this risk relies on multiple layers of controls to reduce the risk of single point-of-failure accidents.”

This includes training and procedures for both avoidance and recovery, which can be enhanced with equipment, such as autopilots to reduce the risk of loss of control, and terrain awareness and warning systems to reduce the risk of controlled flight into terrain.

Mr Mitchell acknowledged the operator had taken a number of actions as a result of the accident including introducing basic instrument flying training and inadvertent IMC recovery training; updating their proficiency check syllabus to include knowledge and practical skills checks for avoiding and recovering from inadvertent IMC; and upgrading the avionics systems on its helicopter fleet to incorporate synthetic vision, a terrain alerting functionality, and, where available, an autopilot.

The ATSB has also recommended that CASA take further safety action to address the risk of inadvertent IMC events in Part 133 helicopter passenger operations.

Read the report: VFR into IMC, loss of control and collision with terrain involving Airbus Helicopters EC130 T2, VH-XWD, near Mount Disappointment, Victoria, on 31 March 2022

It is interesting to note that this 'systemic investigation' was completed in an almost world record time (for Popinjay) of 1 year 9 months and 11 days. It included a prelim report that took approximately 6 weeks to complete and bizarrely 5 (publicly unannounced) updates, which didn't include an interim report on the anniversary date (ICAO Annex 13 para 6.6):  

Updated 4 December 2023 (PS: Rumour has it that Popinjay had an extraordinary management meeting on the same day??)

The external review phase has been completed and the draft report has been updated to a final report. The final report is now under internal review prior to publication.

Updated 24 October 2023

The draft investigation report has been distributed to the directly-involved-parties for external review.

Updated 17 July 2023

The investigation report has been drafted and is now under internal review before distribution to the external directly-involved-parties.

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

Updated 16 June 2023

The ATSB has completed the analysis phase and the investigation has progressed to the report drafting phase.

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

Updated 2 December 2022

The ATSB has successfully retrieved 1-second flightpath data from the pilot’s electronic flight bag (iPad) and downloaded the helicopter’s vehicle and engine multi-function display and Appareo camera, which contained a recording of the accident flight. The engine electronic control unit, which was severely fire damaged, and Garmin GTN750 global positioning system were not downloaded as it was considered unlikely that they would provide additional information about the operation of the helicopter or the accident sequence.

Further investigation

To date, the ATSB has examined and analysed the accident site and wreckage, pilot qualifications and training, medical records for the occupants, vehicle recorded data, meteorological data from the Bureau of Meteorology, interviews and statements, and flight planning and maintenance data. The ATSB will continue to liaise with Victoria Police, and the French Bureau of Enquiry and Analysis for Civil Aviation Safety (BEA) as the accredited representative for the helicopter and engine manufacturers.

The investigation is continuing and will include the review and analysis of the operator’s risk controls and similar occurrences.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

I say bizarrely because the updates are pretty much outlining the fundamental stages (progress) of any ATSB systemic investigation - see HERE. 

IMO what is standout for this investigation is the correspondence/responses in reply to the ATSB's issuing a SI (safety issue) to CASA, that was ultimately escalated to a SR (safety recommendation) with the release of the final report (note that the SI refers to deficiencies in CASR Part 133, which was originally released for industry consultation 24 years ago)...

Action description

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority takes safety action to further address the risk to rotorcraft air transport (Part 133) passenger safety from a visual flight rules inadvertent instrument meteorological conditions event.

Organisation Response
Organisation Civil Aviation Safety Authority

Response Text

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

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

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

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

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

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

"CASA recommends the safety issue is withdrawn" - 

(Note the date of the CASA response is a day after the release of Popinjay's cover up Croc-O-Shite report -  )

Hmm...I've seen plenty of CASA pushback on ATSB safety issues addressed to them but I believe this is a 1st where the regulator 'recommends' they withdraw the SI??

The Popinjay response is equally remarkable and leads to the ultimate issuing of an SR to CASA:

ATSB Response

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

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

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

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

No accidents involving commercial air transport that result in serious injuries or fatalities, no serious injuries or fatalities to third parties as a result of aviation activities and improving safety performance across all sectors.

Therefore, any risk assessment of a fatal commercial air transport accident by CASA should be consistent with Australia’s stated acceptable level of safety performance. To progress towards this level of safety, CASA need to capture lessons learned from fatal accidents in Australia in the Australian aviation standards.

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

 
The reference in bold to the NASP (and the ATSB , CASA as contributing agencies) is intriguing and perhaps shows a naivety of Popinjay that the other 'contributing agencies' and Dept actually believe the NASP is anything more than words on a page and a placation to compliance to ICAO Annex 19 - 

4.2 Acceptable level of safety performance

Each safety goal contributes to an overall acceptable level of safety performance for Australia.
Australia’s acceptable level of safety performance, or the sum output of Australia’s safety goals, is:

No accidents involving commercial air transport that result in serious injuries or fatalities, no
serious injuries or fatalities to third parties as a result of aviation activities and improving safety
performance across all sectors.

(Ref: Pg 16)

Also refer to Appendix A (pg 26):

Safety Enhancement
Initiative - Mitigate contributing factors to Controlled Flight into Terrain.

&..

(pg 28):

Safety Enhancement
Initiative - Mitigate contributing factors to Mid-Air Collision accidents and incidents.

Hmm...and how's that working out?? 

The reference to 'Australian Aviation Standards' is equally intriguing because shouldn't that be - 'ICAO international aviation safety standards' (SARPs)?? 

Hmm...much, much MTF on this one - P2