[Peetwo]

Nearly missed the following from the Oz, but thought it most appropriate for kicking off this thread:

CASA needs to interview after safety risks  

• From: AAP
  
• August 14, 2015 2:30PM
  

CASA should consider developing laws allowing it to interview people after flight safety risks, the NSW deputy state coroner says.  

THE recommendation comes from Deputy State Coroner Paul MacMahon's inquiry into the death of Kathryn Anne Sheppard, who was killed along with pilot Andrew Wilson, when their twin-engine plane crashed at Canley Vale in southwest Sydney in June 2010.
Mr Wilson had declared an emergency just 20 minutes after taking-off from Bankstown Airport and was returning from the Richmond area, but the plane went down about 5km from the runway.

It was also recommended that CASA, the Civil Aviation Safety Authority, update its guidelines for multi-engine aeroplane operations and training.

Mr MacMahon found that Ms Sheppard died from a combination of head injuries and the effects of fire sustained in the crash.

"The aircraft in which she was travelling as a passenger suffered engine failure and as a result impacted with the ground and became engulfed in flames," he said in findings released on Friday.

The plane struck a power pole, crashed and burst into flames in the front yard of a house next to Canley Vale Public School, but no one on the ground was injured.

Teachers herded children to the back of the school and emergency services soon evacuated them to a nearby park, Canley Vale Public School principal Cheryl McBride told AAP at the time.

Four adults and three children, were taken to Liverpool Hospital suffering emotional distress after witnessing the explosion.

 
My apologies to kharon for I did not know the Coroner was due to hand down his findings on this terrible tragedy - condolences to family, friends & former work colleagues of Kathryn Sheppard & Andrew Wilson.
P2

[Kharon]

Cheese – Anyone?

One of the many terribly sad things about these deaths is that the risk of the accident happening could have been reduced.  I am tempted to say prevented but that would be trespass into the realm of the gods.   But, common sense and good governance could have assisted; CASA were warned that an accident would happen and did nothing; well, nothing of any value to air safety.  

Skidmore has been made aware of this warning, ATSB were made aware, after the fact, of the problems which beset Andrew, as have the Senate committee which made inquiry into Pel-Air, as part of a general briefing on the disgraceful state of affairs within CASA. CASA are now taking the extraordinary step of denying that the warnings were brought to their attention; before the fact.  This, despite empirical evidence; seemingly quite prepared to call half a dozen or so peerless witness liars for saying so. But that is par for the CASA course which will not be changed, not by Parliament, not by Senate, not by Coroner, not by a few deaths and certainly not by Skidmore.  

None of this has made the slightest difference, things have only changed for the worse; not the better.  The system remains rotten, the Senate powerless, ATSB complicit and the Coroner recommendations, based on whatever evidence was allowed in, as nugatory as ever.  

No one that I am aware of who made statements to the ATSB investigation was called as witness; I will check around to make certain; but I believe there were two fatal accidents being heard as one case; again, I’ll have to check and see exactly where, what, who and how.  

I guess we need a transcript.  But I confess to a lack of energy and interest for a pointless battle which cannot be won.  My sadness and anger over the deaths of John Hamilton, Kath Sheppard and Andy Wilson has diminished over the six years (+/-) of waiting.  The ATSB reports in response in both incidents were less than satisfactory, as was the CASA manipulation of the entire situation.

Three more bodies added to the pile.  Another raft of Coronial recommendations to add to the mouldering heap of things to be ignored, which is probably a good thing; considering what the coroners seem to be given to work with.

Aye, it’s a sad thing in every sense of the word.  Lets see if we can find a transcript; I’ll help in one more vainglorious attempt to get changes to the system, and oust those who manipulated and abused it.  But I will not hold my breath; pointless.

Safe home, John, Kath and Andy.  Godspeed.

And death shall have no dominion.

Dead man naked they shall be one
With the man in the wind and the west moon; 
When their bones are picked clean and the clean bones gone,
They shall have stars at elbow and foot; 
Though they go mad they shall be sane,
Though they sink through the sea they shall rise again; 
Though lovers be lost love shall not; 
And death shall have no dominion.

And death shall have no dominion.
Under the windings of the sea
They lying long shall not die windily; 
Twisting on racks when sinews give way,
Strapped to a wheel, yet they shall not break; 
Faith in their hands shall snap in two,
And the unicorn evils run them through; 
Split all ends up they shan't crack; 
And death shall have no dominion.

And death shall have no dominion.
No more may gulls cry at their ears
Or waves break loud on the seashores; 
Where blew a flower may a flower no more
Lift its head to the blows of the rain; 
Though they be mad and dead as nails,
Heads of the characters hammer through daisies; 
Break in the sun till the sun breaks down,
And death shall have no dominion.  (Dylan Thomas),

[crankybastards]

Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

[Peetwo]

Channel 9 News, which ran the story in Sydney last night may be interested in a follow up if they had documents to the effect above.

Every time a fatal accident happens CASA must be implicated either in neglect of oversight, incompetence or maintaining a mischief. It's not good enough to let The "Department of Funny Handshakes" gain traction for the impetus of their "New World Order". A new World where aviation is non existent except for the Illuminati.

CASA must suffer the harangue of thousands shouting "I TOLD YOU SO", I TOLD YOU SO.

cranky for your benefit, & others interested, here is a further "K" comment from a post off "Overdue & Obfuscated" relevant to the Canley Vale tragedy and the subsequent ATSB/CASA cover-up after the fact: O&O #post1

K" -comment - The words Canley Vale, Andy Wilson, Cathy Sheppard or VH-PGW will mean little to many outside Australia.   Norfolk Island and VH-NGA may mean something as that was a widely carried story.  The focus of interest lays in the fact that neither of these accidents seem to have been reported to ICAO as per the book.
 

I find the similarities and parallels between the two 'missing' report intriguing.  We know that the ATSB system for reporting is spot on, the TSBC tell us so.  Whoever is ultimately responsible for the despatch of those reports clearly has a bullet proof system and clearly uses it, as every other report transmission has been made in a timely, proper manner; which begs the question.  How did these two heavily criticised, highly suspect reports slip through the robust ATSB system net.  It's probably just a coincidence that the same crew managed and edited both final reports, funny how things like that just happen.  Must be one of them there 'aberrations'.   

No doubt the word weasels are hard at, developing 'credible' excuses, I expect some wretched clerical type will get moved, an apology issued and all will be bright and rosy, once again in the DoIT garden.  Terrific.

Also for the benefit of readers here is a link for a PAIN supplementary submission to the Senate PelAir cover-up inquiry - PGW Canley Vale pdf.

It is also worth noting that the ATSB also white-washed, subverted, obfuscated the records that they presented as all investigative material to the Canadian Transport Safety Board - Independent review of the Australian Transport Safety Bureau's investigation methodologies and processes.
 
MTF...P2

[Kharon]

Cheers P2; that summary document was provided to the Senate committee in an abridged fashion, stripped down to make it an easy read, non technical introduction to a reasonably simple case and overview of the problems industry have to deal with. I have just been right through the PAIN files related to this one accident, which are technical and operationally based; the picture which emerges leading up to and the aftermath is a disgrace. The HOTAC ‘notes’ on the operating practices, procedures and ‘check/training’ with hindsight, show a very clear path to a fatal accident.

I’ve also read some of the ‘statements’ made to the ATSB and CASA; all confidential, but made available to the PAIN library; what a tale they tell.

What I fail to understand is why neither the Senate Inquiry or Forsyth insisted on an independent inquiry into the Canley Vale accident and subsequent events. Ye gods it was all there, enough to put a stopper on the whole thing, right there, right then. Yet when I look about at who’s dead, who’s left standing and the collateral damage done, to enforce a predetermined outcome, produce a very suspect report and an escape path for CASA to slither down; it makes me wonder just how deep and how far the willingness to protect the ‘status quo’ stretches.

Wish I’d left it alone; perhaps Karma will step in; but I’m not betting on that.

Selah.

[Gobbledock]

PFirstly let's cut to the chase. The ATsB's current woeful and farcical condition can be traced back to July 1, 2009. Full stop.

Secondly, names such as Ross Lovell, Samantha Hare, Sally Urquhart, Shane Urquhart, Cathy Sheppard, Andy Wilson, and Karen Casey mean very little outside of their immediate family and friends circle, except to a handful of IOS justice seekers on this website and a handful of Senators.
The rest of society including most of the media and virtually all government authorities and representatives couldn't give a fistful of monkey crap. Those in obsfucatory power (new word) are only interested in protecting their own asses or the worthless ass of a Minister, or protecting their highly remunerated existence on this planet and their special rights to benefit from unlimited trough access. And they view the above names list and those who support them as a barrier and a thorn in the side to their political and bureaucratically comfortable, opulent lifestyle.

At least we have comfort in knowing that at some point in time justice will be served when the Ferryman comes to pick up these stains on society and he drops them off at the correct destination.

P_666

[Peetwo]

For the record the only publicly available document from the Kathryn Sheppard inquest was the Coroner's recommendations:

Recommendations made in accordance with Section 82 (1) Coroners Act 2009:

To the Chief Executive Officer – Civil Aviation Safety Authority (CASA)

1. That CASA finalise the guidance material for CAAP 5.23 such that the guidance material is completed and released as soon as possible noting that the guidance material in question provides for multi-engine aeroplane operations and training to support the flight standard in Appendix A of s.1.2 of the CAAP relating to engine failure in the cruise;

2. That CASA undertake public consultations in order to assist CASA in the development of a legislative proposal enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that;

a. a significant safety risk exists or existed in an aviation operation; and 2

b. evidence of a witness or witnesses likely to have knowledge of an aviation safety risk cannot be obtained in any other way.

   
Well I guess that's it until the Andrew Wilson inquest...
The reference to the CAAP 5.23 is very interesting because it has only recently been put to a DRAFT amendment - see here.
Here is an interesting perspective from Stan on part of that DRAFT document...

I have always found CAAPs to be informative and generally useful documents, that is until I came across this one. However noting the name of the contact it is now clear to me.

With the publication of this CAAP it appears that CAsA is now further subcontracting several important safety tasks to “the pilot”. Note also the reference to Part 23 FARs 23.65 as though we can’t write our own Australia specific requirements. We lead the world in our legislative inventiveness and quantity. What an affront.
I am thinking of starting a course to enable “the pilot” to be well informed to make [such] judgements.
The “nanny state” springs to mind. Or is it “control freaks”
  
DRAFT CAAP 5.23-1(2) Multi-engine aeroplane operations and training

4.6.1 Subpart 61.L of CASR includes the legislative requirements for aircraft ratings and endorsement as applicable to the aircraft type the pilot intends to operate.

4.7 Certification of multi-engine aeroplanes

4.7.1 An understanding of the weight and performance limitations of multi-engine aeroplanes requires an understanding of the performance of single-engine aeroplanes.

4.7.2 The Pilots Operating Handbook (POH) or Flight Manual for most single-engine aeroplanes provides for two requirements for climb capability:

• Take-off - the aeroplane in the take-off configuration at maximum weight with maximum power must have an adequate climb capability in standard atmospheric conditions.

For most light aeroplane types, adequate climb capability is defined as either 300 feet per minute (fpm) or a gradient of 1:12 (8.3%) at sea level. –

This definition is given in Part 23 of the US FAA Federal Aviation Regulations (FAR) regulations (see FAR 23.65). Paragraph 7.1 of CAO 20.7.4 specifies a minimum takeoff gradient of 6%. CAO 20.7.4 is expected to be repealed when Parts 91 and 135 of CASR commence

5.3 Choosing a flying training organisation

5.3.1 Many FTOs offer multi-engine training. This CAAP emphasises the importance of receiving good training, particularly for a pilot’s first multi-engine endorsement, and the selection of a flight training operator will [sic] their decision. It is important for the pilot to be well informed when making such a decision.

5.3.2 A personal recommendation from another pilot is always helpful. However, the pilot should not consider a recommendation based solely on cost. It would be worthwhile for the pilot to research a number of operators across the market to see what they have to offer.

5.3.3 The first item to examine is the syllabus of training that all FTOs must have in their operations manual. (Shouldn’t such conform to the standard dictated by CAsA) It should detail in a logical sequence all the theory and flight training exercises involved in the course. For guidance, refer to the recommended syllabus at Appendix B and map the course against this document. The pilot should ask how many flying hours will be involved. Experience has shown that it is unlikely that all the flight sequences for an initial multi-engine endorsement can be adequately taught in less than 5-7 hours of flight time.

 5.3.4 The same time frame applies to the aeronautical knowledge training. A structured, well-run course should be the pilot’s goal. If they choose a flying instructor to conduct their training, they should ensure that the organisation has an appropriate written syllabus and training plan.

5.3.5 CASA requires training providers to supply adequate and appropriate training facilities before an AOC is issued. However, the pilot should examine the facilities and look for:
                • briefing facilities (lecture rooms and training aids)
• flight manuals and checklists • training notes
• reference libraries • comprehensive training records
• sufficient experienced instructors available at the time you require
• flight testing capability close to the end of training.

5.3.6 The pilot should then inspect the aircraft. It should be well presented and clean. The interiors should be neat with no unnecessary equipment or publications left inside. Windows should be clean and unscratched, and the condition of the paintwork is often an indicator of the care taken of the aircraft.

5.3.7 To ensure training is not delayed due to aircraft unserviceabilities, the pilot should also:
• examine maintenance documents to ensure there are no long-standing unserviceabilities
• review the maintenance release to ensure that unserviceabilities are entered (as sometimes this is not done).

5.3.8 The next component to review is the flight instructor. The value of a flight instructor who helps the pilot gain knowledge and skills and develop a positive and robust safety culture cannot be over emphasised. The pilot should ensure they are satisfied with the instructor’s performance and professional behaviour. (I always thought it was CAsA who needed to be satisfied)

It is important for the pilot to:
• discuss their aims and any concerns they may have about the flight training
• establish good communication
• determine that the instructor is available when they are. Some training operators will substitute flight instructors and this can cause time wasting while the new instructor reassesses the trainee to establish what training is required. (isn’t this why Australia has this unique requirement for AOCs and won’t allow competent rated instructors to provide training without being bound to an FTO)

5.3.9 The pilot should not just accept an instructor that they feel uncomfortable with or have doubts about

  
So is the DRAFT CAAP just coincidence or something else, like protecting CASA from any future potential liability?
c/o Cynical knuckle-dragger...P2  

[Sandy Reith]

[attachment=12]I would have thought that "compulsory sworn statements" (coroner's report, preceeding comment) are more likely, and correctly, within the purview of properly convened court proceedings. Otherwise we are on the path to reverse the civilising gains made since Magna Carta in the field of justice. Furthermore its only a small step over the line to coercion, waterboarding etc., torture.  

In regard to the CAAP, which reads like instructions by a kindergarten teacher, demonstrates clearly that there is no respect for General Aviation professionals, and no prospect of top down reform within CASA.

Good point made that our flight instructors must be employed by an Air Operator Certificate holder, unlike the USA where some 70% of pilots are trained by individual instructors. They do not have to fund and maintain the super expensive and time consuming training regime that is the unhappy scene for what is left of GA flying training in Australia. Couple this with the extremely heavy handed criminal sanctions applying is it any wonder that people are just walking away?

Sadly, safety is going down the drain in lockstep with General Aviation dying by a thousand cuts. I'm seeing things in maintenance that show lack of knowledge and recency. There are increasingly high costs and lack of competition in all fields of GA. The loss of experienced personnel and businesses, especially from our secondary airports. Loss of refueling facilities. Thousands of Australian aviators migrating to the low weight category, not because the aircraft are more suitable, very often much less suitable, but because the regulatory regime is more practical.

So whenever anything emanates from CASA about safety, understand the big lie, the disgraceful self serving, and the raison d'etre of a so-called 'independent government business unit'.

The graveyard spiral will continue unless we achieve Parliamentary action.

A letter I received in 1989 is attached, I keep it pinned to my office wall.

[Peetwo]

Bye the bye - Had to laugh at this tweet from CAsA...


@CASABriefing 4m4 minutes ago
Have a comprehensive knowledge of Australia's #aviation safety legislation? Join CASA as a National Team Leader: https://www.casa.gov.au/about-casa/standard-page/careers-casa …

Is there anyone out there that would fit the bill..anyone??

In regards to Sandy's 1st paragraph & in what I believe is a far more significant recommendation by the Coroner:

2. That CASA undertake public consultations in order to assist CASA in the development of a legislative proposal enabling CASA to compel the attendance of persons at compulsory sworn interviews to answer questions concerning specific aviation and safety measures where a reasonable suspicion exists that;

a. a significant safety risk exists or existed in an aviation operation; and 2

b. evidence of a witness or witnesses likely to have knowledge of an aviation safety risk cannot be obtained in any other way.

Can anyone really imagine CASA following proper legal process if (a big if??) they were to accept that recommendation in it's entirety?

For example if we refer to pg 4 of the PAIN Canley Vale supplementary submission - http://auntypru.com/wp-content/uploads/2...Canley.pdf

...6) Under Parliamentary privilege, in camera there are upward of 12 independent
witnesses who are prepared to provide their statements as were freely given to
assist the ATSB. The sworn statements make a nonsense of the thinly disguised,
manipulated conclusions drawn in the ATSB final report.


7) CASA was made aware of the serious concerns of two senior Check and
Training pilots related to the training practices of the incumbent Skymaster
chief pilot . One senior pilot made two written attempts to engage CASA,
predicting a fatal accident if the matters raised in the report were not
addressed. The prediction proved to be tragically accurate. Refer 'Cheese'
page 12.

a) CASA dismissed the written reports offered by a senior Check and Training
pilot, qualified and approved as an Approved Testing Officer.
b) CASA dismissed the written report provided to Skymaster management,
highlighting deficiencies in both operational standards and the published
company operating procedures manuals.
 c) CASA insisted that the report be removed from the Safety system data
base and that the matter be dealt with 'in house'.
d) CASA 'warned off' the Airtex chief pilot and Head of Check Training,
advising them not to interfere in the affairs of a 'separate' although sister
company. (Skymaster).

8) CASA and ATSB were made aware of the horrendous working hours imposed
by the Operations Manger, enforced by the Skymaster chief pilot; related to
length of duty period, the amount of sectors required to be operated and the
fiscal penalties for not 'going along'.

9) CASA and ATSB were made aware of the marginal, cut-corner maintenance
practices of the chief engineer. The generally poor, though 'legal' condition of
the aged Skymaster aircraft fleet; and the unspoken law against complaining.
The status quo was fully supported by the Skymaster chief pilot, who was an
enforcer of the 'there are no maintenance issues' philosophy, also a repeat
offender in the entrenched art of never, ever committing an aircraft fault to
paper, unless there was no other option.

10) CASA and ATSB were made aware of the pressures on junior pilots, brought
by a Skymaster major client, Heron Airlines; fully supported by the Operations
manager and Skymaster chief pilot to carry 'heavy' loads over extensive
distances, to the detriment of aircraft fuel planning and performance rules.

a) Pilots who expressed concerns about being exhausted were 'sidelined' for a
period of attitude adjustment.
b) Pilots who expressed concerns about operating aircraft not quite 100%
operationally suitable and serviceable were 'sidelined' for a period of attitude
adjustment.
c) Pilots, 'under contract' who expressed concerns about being caught out,
under-fuelled, over weight, with no escape should an engine fail at a critical
point during the flight were 'sidelined' for a period of attitude adjustment...

Now can anyone imagine CASA LSD wanting to follow proper legal process in getting possibly 12 sworn, recorded witness statements in regards to this matter?- In your dreams..

P2 Comment: Has the Coroner in this case, very cleverly lain down a challenge to CASA legal in the lead up to the next inquest into this accident??

MTF...P2

[Kharon]

I wonder how close to the truth the coroner will get with the inquests.  I hear the Botany Bay and Canley Vale accident are to be heard together; which of it’s self is passing strange.  On the wind is word that CASA have rejected outright any and all claims that they were alerted, the people involved in that warning have been administratively side lined, denigrated and professionally undermined, the witness all deemed to be telling porkies apparently.  The CASA and ATSB joint effort whitewash is finally surfacing, to leave yet another ugly mark.

When the final inquest is over and the dust has settled, the Bankstown Chronical version of the these two sad events will be made public.  Until then, we can only hope that the coroners recommendation is an indication that he is aware of the intricacies.

It has taken a long, long while for this to surface; too long for the families and friends.  The human face of the CASA all know so well, now with mustachio’s.  

Selah.

[Peetwo]

PelAir & beyond - 'Lest we forget'

The PelAir Norfolk Island ditching came so close to being our first international aviation fatal accident. All on-board miraculously survived and therefore the accident never ended up in the Coroner's Court. However there was still much to be learnt - or there should have been much to be learnt - from one of the rarest survived aviation occurrences, that is a night ditching in open sea conditions of an aircraft. 

However IMO the PelAir cover-up highlights perfectly how our aviation safety system (Annex 19 SSP) is currently so fundamentally & reprehensively broken.

As a reminder of how far we have drifted from the ICAO principles for an effective State SSP, one need not go past the following post from Ziggy...  - The tale of Karen Casey #post65  

Ziggy

Thank you for kind words of determination and inspiration.

A double whammy at the moment.


Personal matter...just waiting.


Re-Investigation. Absolute disgrace.

I have Effin had enough of being psychologically tormented by the incompetent certain so called "professionals" from both CASA & the ATSB.

Mr Abbott,

It's time for a RC into Australian Aviation Safety, Regulation and Investigation.

Firstly, the re-investigation so far of the first International Australian Crash was called an aberration and frowned upon by many reports and the Senate.
The NTSB etc. Ask your Deputy and his Treasurer. I'm sure they could give you Governmental "truths".

Hear me when I ask. From an actual survivor. The re-investigation of VH-NGA still amazes as the games continue. Why?

Your ATSB Commissioner clearly withheld evidence. This has been proven, yet he is still, Commissioner in charge of this re-investigation. How can I trust this report to flow through the same people, then it pass through Mr Dolans' hands again with confidence. Trust and Truss. No, how?

I met with your DP Mr Truss a few years ago about Aviation issues, with documents. Dismissed really, although all the evidence was sitting in front of him. So very absent. Given I saw Mr John Sharp in the Parliament elevator lobby that day, it was clear I was just an appointment of convenience. Mr Sharp had an appointment with him too. Expanding his business. Did not even recognise me. I was in one of his Jets, Operated by the company he chairs.

Let's not forget the timely political donations made. Ignored. Incompetent operator with the blessing of CASA. Ignored. The Chief Pilot then jets out of there, to be employed by CASA as an inspector. How? Ignored!

Now, people know that the life-vests have been miraculously found after five and a half years. Stored at NFI Police station.

So the ATSB invite an observer from CASA & P/A to view and watch manufacturer testing.

What about the witnesses who actually wore them?

How do I know it's the same life-vest? No person in that room would be able to correctly identify the vests.

I will be there. Annex 13 folks. Spoken to Manufacturer, does not seem to be a problem, only issue is from the ATSB. Fair and Australian. I don't think so.

Mr Abbott & Co, you can't keep hiding the fact that the Pel Air incident will be tucked away nicely. Just as the omission to the ICAO of correct reporting of this incident was found.

Treat the occupants like dirt, gag their mouths because we wouldn't want all to know that it's the same Commissioner and DP under your wing Mr Abbott; in charge of another controversial Aviation Incident.

Might want to have a chat with Albo too. Not all opposition are innocent of theses atrocities we have had to endure because we are an inconvenient truth to your Departments Incompetence.

It's all quite dangerous practice from leaders walking the path of preserve thy self.

How is a Governmental portfolio suppose to Evolve with Time if you don't LISTEN TO YOUR PEOPLE?

Especially Aviation Safety and Investigation.

An Australian Citizen that has had enough of the Political bullshit surrounding this disgrace towards your own fellow citizens.

Karen Casey

MTF...P2

[Peetwo]

Beyond Reason - & the pale??

Very much related to 'closing the safety loop' is some recent posts on the O&O thread here: 

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason model is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning...

That was followed up by this excellent post from the Ferryman that highlights the various holes in the Norfolk Island ditching Swiss Cheese:

A journey, through the Swiss cheese.

Do you remember – one of the first things ever taught – apart from Up, Down, Left, Right and ‘it nuffin was – escape.  This was lest you required your ‘superior’ skills to extricate your arse from a situation in which your superior talent should never had placed you.  The lesson is a simple one – paddock – paddock – paddock; why?  Well if the single fan up front quits – over the tiger country – where can you park the beast.  It’s a habit, deep ingrained; same-same with weather, engine out in fact, the whole gamut of caution and back door theory, so that when things turn unpleasant – there is a viable alternative...

cont/- ..So the answer to the question, why paper over the cracks instead of plugging the holes becomes crystal clear – ASA, BoM, CASA, Pel-Air were all ‘slices’ with holes and most definitely, IMO, own a large share of the event, as does James.

1) - The conclusion is stark – James acknowledged the errors made and apologised, then set about correcting his part to ensure  that a repeat performance was not going happen.

2) - ASA ducked the issue, threw both Nadi and Auckland under bus, and joined in the cover up of systematic failure. Which fooled no one, least of all the Senate committee.

3) - BoM so secure in their latitude to be wrong in forecast and their wriggle room cast in law need make no reparation or apology – their system secure, their hands legally clean.  It has always been so, even being asleep at the wheel is forgivable – legally.  

4) - CASA realising that they had been partly to blame by not only ‘accepting’ flawed procedure, failing to realise the fuel policy was ‘incomplete’, failing to realise there were serious holes in the check training procedure; and, IMO worst of all, allowing the operation to continue with almost 20 potentially serious ‘events’ on record.  Many operations have been closed down for much less.  To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence.  No apology, no corrections.  Just another pilot crucified...

 So I've decided to start by examining the Ferryman's - "IMO worst of all"- in his identified Swiss cheese hole 4; because I believe it is pivotal to Senator Fawcett's original question - to Murky Mandarin & his Department - on how best to close the safety loop. 

 A journey, through the Swiss cheese - Part II

To continue P6 in the above post said:

...allowing the operation to continue with almost 20 potentially serious ‘events’ on record.  Many operations have been closed down for much less.  To this day, the errors have not been acknowledged, there is no effective remedy in place for rehabilitation, nor is there any intent to correct the gross negligence.  No apology, no corrections.  Just another pilot crucified...

   
The 'almost 20' incidents to which he refers were on the record in the ASA answer to QON for PelAir inquiry public hearing on the 19 Nov 2012 - Answers to questions taken on notice on 19 November 2012, in Canberra; (PDF 9401KB):

8. HANSARD, PG 9

Senator FAWCETT: Could you take on notice whether you passed on to Pel-Air the
concerns about their Westwind aircraft.

Mr Harfield: Yes.

Answer:

In the period five years before the Norfolk Island accident (2004 to 2009) Airservices

reported to both CASA and the ATSB, 19 safety incidents that were known to Airservices involving VH-NGA.

In July 2005, VH-NGA was involved in a safety incident during a flight from Nowra to
Darwin whereby the aircraft was unable to maintain it’s assigned level in RVSM airspace
and another aircraft was therefore required to change its altitude in order to maintain
the separation standard. Pel-Air was informed about this incident under a standing
Letter of Agreement.

Also in the period, VH-NGA was involved in 18 other safety incidents – 16 were pilot or
aircraft attributable (2 engine failure, 2 fuel dumps, 1 Loss of Separation, 3 incorrect
time and position reporting, 8 pilot errors) and two were air traffic control attributable
information display errors. Pel-Air was also informed about the details of these
incidents under the Letter of Agreement.

 
 And that was just for one aircraft??- UFB!
But what is probably worse is that not one of these incidents - that were captured by ASA & forwarded to the ATSB & CASA - was featured, further investigated or even remotely mentioned in either; the CASA Special Audit Report or their infamous CAIR09/3; nor does it appear that such records were requested from CASA or the ATSB in the course of their original investigations .  I guess they were too busy shovelling yet more shit on top of the DJ mound - again UFB!    
MTF..P2 

[Peetwo]

TICK TOCK goes the Miniscule clock??

Running along the ever more critical theme - i.e. Closing the safety loop - there was released from the ATSB today

Aircraft loading events involving VH-VWT, Airbus A321, Melbourne Airport, Vic. on 29 October 2015 and VH-VQG, Airbus A320, Brisbane Airport, Qld on 19 October 2015

 
Investigation number: AO-2015-139
Investigation status: Active
 

• Summary
  

Summary
On 29 October 2015, an Airbus A321, registered VH-VWT and operated by Jetstar Airways (Jetstar), was scheduled to conduct a passenger flight from Melbourne, Victoria, to Perth, Western Australia. During the take-off roll, the pilot flying noticed that the aircraft was nose-heavy and required an almost full aft control input to raise the aircraft’s nose. Once airborne, the flight crew requested the cabin crew to confirm the passenger numbers and seating locations. The flight crew re-entered the updated information into the flight management computer and identified that the aircraft was outside the aircraft’s loading limits for take-off and landing. Passengers were relocated within the aircraft cabin to return the aircraft to within allowable limits for the remainder of the flight and landing.
Ten days earlier, an Airbus A320, registered VH-VQG and being operated by Jetstar, was being prepared for a scheduled passenger flight from Brisbane, Queensland, to Melbourne. During the passenger boarding process, the flight crew were advised of a discrepancy at the passenger check-in, and that 12 passengers were still to board the aircraft. A short time later, the flight crew were advised that the issue had been resolved, and they were given final passenger numbers.

During the flight to Melbourne, the flight crew requested the cabin crew to confirm the total number of passengers on board the aircraft. The passenger count in the cabin suggested that the aircraft departed Brisbane with 16 more passengers than advised, and the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight. The crew recalculated the aircraft’s landing data prior to the descent into Melbourne.

The ATSB has commenced an investigation into these two aircraft loading events, which will include:

• interviews with the flight and ground operations crews
  
• a review of the Jetstar internal procedures regarding aircraft loading
  
• a review of preventative- and recovery-type risk controls for aircraft loading.
  

_________________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update. 



 

Which was diligently caught and reported on, with updates, by Ben Sandilands...

Two serious Jetstar incidents under ATSB investigation

Ben Sandilands | Dec 04, 2015 8:27AM |


A Jetstar A321, a jet so badly loaded at Melbourne in October it struggled to get airborne

After an unexplained delay two incidents involving Jetstar domestic flights in October are being investigated by the ATSB, with one of them placing a jet equipped with more than 215 seats in grave danger.

On 19 October a Jetstar A32o left Brisbane for Melbourne with 16 more passengers on board than advised, meaning the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight.

On 29 October a Jetstar A321 was found to be so nose heavy during the take off roll from Melbourne bound for Perth that it required an almost full aft control input to raise the aircraft’s noses and become airborne.

It is understood that Jetstar promptly reported both incidents to the ATSB.

The flight had been dispatched with incorrect load information in its flight management computer which placed the jet outside its loading limits for take-off and landing.

This was an incident that could have ended in a fireball killing hundreds of people. It is almost inconceivable that an Australian airline, under the diligent oversight of its safety regulator CASA, could place so many people at risk through such a fundamental failure of basic operational procedures.

Both incidents are grounds for an urgent inquiry into the fitness of Jetstar to continue to hold an air operator certificate, and the appointment of an independent audit into the capacity of CASA to discharge its obligations to maintain air safety standards in this country.

Tiger Airways was grounded by CASA in 2011 for busting the minimum safe altitude over houses in Leopold near Geelong (as well as ignoring repeated safety warnings from the regulator).

The risks Tiger posed to air safety in Australia were however manifestly less than those evidenced in these and earlier serious incidents involving Jetstar. For an Australian licensed carrier to be dispatching jets before knowing how many passengers were on board, thus invalidating critical performance calculations on a flight by flight basis is one very serious matter.

But the discovery mid take off that a jet, an A321, was so dangerously loaded that it was almost uncontrollable, is a warning to the Australian government, and its dysfunctional safety regulator, as well as to anyone thinking of flying Jetstar, that there is something profoundly wrong in the management and operating culture of this airline.

You couldn’t make up worse scenarios for the operations of a scheduled mainline airline than those that played out in these incidents.

It is important also to get an explanation as to why their notification to the ATSB seems to have taken so long. Integrity in the reporting of safety incidents is a critical element in airline safety in the developed world.

The ATSB notifications of these incidents are about as blunt as any in recent years and can be read in full here.

Jetstar responds:
A spokesperson for Jetstar says “We’re investigating these events and working closely with the ATSB to assist with its inquiries.

“Since these incidents took place in October, we have put additional measures in place to check our flights have been loaded correctly and that aircraft weight and balance is properly accounted for.

“We’ve had no flights operate with this type of error since we introduced these measures.”

CASA responds:
CASA has begun its own investigation into the two Jetstar passenger loading incidents.
This investigation is looking at the root causes of the passenger loading errors, relevant systems and processes and Jetstar’s subsequent actions.

CASA’s investigation is running parallel to the investigation being conducted by the Australian Transport Safety Bureau and focusses on regulatory compliance and ongoing safety of flight.

The travelling public can be assured CASA will take all appropriate actions to ensure Jetstar has robust and appropriate systems and processes in place to ensure passenger loading mistakes are not made.

CASA is oversighting the changes Jetstar have made in relation to passenger loading and aircraft weight and balance following the October incidents.

From ABC World Today program:

Jetstar investigated by aviation safety and regulatory authorities over passenger loading issues


Will Ockenden reported this story on Friday, December 4, 2015 12:20:01
About JW Player 6.11.4923 (Ads edition)
 

| MP3 download

Transcript available shortly.

Wake up Jeff...err Wazza - sheesh


MTF..P2

[Gobbledock]

No surprise with this incident. Ever since LCC operations started here in Australia - VA, JQ and TT, there have been myriads of load, weight, out of trim issues reported to CAsA. Many more than in the day of the duopoly of QF and AN. CAsA slapped together a minimal inefficient ground ops team in 2009 from memory, but not enough has been done. I've said for years that it wouldn't surprise me that if one day we have a narrow body accident caused by a load control mistake, 4 tonne ULD not locked down or a general bugger up such as unreported GSE contact with an airframe or a cargo door not properly closed.

The fact that the crew of this flight allegedly had to pull the stick back fully on rotation and knew that she was way out of trim is serious shit. One day it won't get off the ground.

Meanwhile CAsA are too busy pinging pilots for having their caps on crooked, or they are too busy heading to Montreal for 5 star rorts.

TICK TOCK indeed Miniscule

[Peetwo]

TICK TOCK goes the Miniscule clock??

Running along the ever more critical theme - i.e. Closing the safety loop - there was released from the ATSB today

Aircraft loading events involving VH-VWT, Airbus A321, Melbourne Airport, Vic. on 29 October 2015 and VH-VQG, Airbus A320, Brisbane Airport, Qld on 19 October 2015

 
Investigation number: AO-2015-139
Investigation status: Active
 

• Summary
  

Summary
On 29 October 2015, an Airbus A321, registered VH-VWT and operated by Jetstar Airways (Jetstar), was scheduled to conduct a passenger flight from Melbourne, Victoria, to Perth, Western Australia. During the take-off roll, the pilot flying noticed that the aircraft was nose-heavy and required an almost full aft control input to raise the aircraft’s nose. Once airborne, the flight crew requested the cabin crew to confirm the passenger numbers and seating locations. The flight crew re-entered the updated information into the flight management computer and identified that the aircraft was outside the aircraft’s loading limits for take-off and landing. Passengers were relocated within the aircraft cabin to return the aircraft to within allowable limits for the remainder of the flight and landing.
Ten days earlier, an Airbus A320, registered VH-VQG and being operated by Jetstar, was being prepared for a scheduled passenger flight from Brisbane, Queensland, to Melbourne. During the passenger boarding process, the flight crew were advised of a discrepancy at the passenger check-in, and that 12 passengers were still to board the aircraft. A short time later, the flight crew were advised that the issue had been resolved, and they were given final passenger numbers.

During the flight to Melbourne, the flight crew requested the cabin crew to confirm the total number of passengers on board the aircraft. The passenger count in the cabin suggested that the aircraft departed Brisbane with 16 more passengers than advised, and the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight. The crew recalculated the aircraft’s landing data prior to the descent into Melbourne.

The ATSB has commenced an investigation into these two aircraft loading events, which will include:

• interviews with the flight and ground operations crews
  
• a review of the Jetstar internal procedures regarding aircraft loading
  
• a review of preventative- and recovery-type risk controls for aircraft loading.
  

_________________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update. 



 

Which was diligently caught and reported on, with updates, by Ben Sandilands...

Two serious Jetstar incidents under ATSB investigation

Ben Sandilands | Dec 04, 2015 8:27AM |


A Jetstar A321, a jet so badly loaded at Melbourne in October it struggled to get airborne

After an unexplained delay two incidents involving Jetstar domestic flights in October are being investigated by the ATSB, with one of them placing a jet equipped with more than 215 seats in grave danger.

On 19 October a Jetstar A32o left Brisbane for Melbourne with 16 more passengers on board than advised, meaning the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight.

On 29 October a Jetstar A321 was found to be so nose heavy during the take off roll from Melbourne bound for Perth that it required an almost full aft control input to raise the aircraft’s noses and become airborne.

It is understood that Jetstar promptly reported both incidents to the ATSB.

The flight had been dispatched with incorrect load information in its flight management computer which placed the jet outside its loading limits for take-off and landing.

This was an incident that could have ended in a fireball killing hundreds of people. It is almost inconceivable that an Australian airline, under the diligent oversight of its safety regulator CASA, could place so many people at risk through such a fundamental failure of basic operational procedures.

Both incidents are grounds for an urgent inquiry into the fitness of Jetstar to continue to hold an air operator certificate, and the appointment of an independent audit into the capacity of CASA to discharge its obligations to maintain air safety standards in this country.

Tiger Airways was grounded by CASA in 2011 for busting the minimum safe altitude over houses in Leopold near Geelong (as well as ignoring repeated safety warnings from the regulator).

The risks Tiger posed to air safety in Australia were however manifestly less than those evidenced in these and earlier serious incidents involving Jetstar. For an Australian licensed carrier to be dispatching jets before knowing how many passengers were on board, thus invalidating critical performance calculations on a flight by flight basis is one very serious matter.

But the discovery mid take off that a jet, an A321, was so dangerously loaded that it was almost uncontrollable, is a warning to the Australian government, and its dysfunctional safety regulator, as well as to anyone thinking of flying Jetstar, that there is something profoundly wrong in the management and operating culture of this airline.

You couldn’t make up worse scenarios for the operations of a scheduled mainline airline than those that played out in these incidents.

It is important also to get an explanation as to why their notification to the ATSB seems to have taken so long. Integrity in the reporting of safety incidents is a critical element in airline safety in the developed world.

The ATSB notifications of these incidents are about as blunt as any in recent years and can be read in full here.

Jetstar responds:
A spokesperson for Jetstar says “We’re investigating these events and working closely with the ATSB to assist with its inquiries.

“Since these incidents took place in October, we have put additional measures in place to check our flights have been loaded correctly and that aircraft weight and balance is properly accounted for.

“We’ve had no flights operate with this type of error since we introduced these measures.”

CASA responds:
CASA has begun its own investigation into the two Jetstar passenger loading incidents.
This investigation is looking at the root causes of the passenger loading errors, relevant systems and processes and Jetstar’s subsequent actions.

CASA’s investigation is running parallel to the investigation being conducted by the Australian Transport Safety Bureau and focusses on regulatory compliance and ongoing safety of flight.

The travelling public can be assured CASA will take all appropriate actions to ensure Jetstar has robust and appropriate systems and processes in place to ensure passenger loading mistakes are not made.

CASA is oversighting the changes Jetstar have made in relation to passenger loading and aircraft weight and balance following the October incidents.

From ABC World Today program:

Jetstar investigated by aviation safety and regulatory authorities over passenger loading issues


Will Ockenden reported this story on Friday, December 4, 2015 12:20:01
About JW Player 6.11.4923 (Ads edition)
 

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Transcript available shortly.

KIM LANDERS: Budget airline Jetstar is facing investigations from two aviation safety and regulatory bodies after making serious mistakes about the number of passengers on flights.


In one October flight, passengers were asked to move after takeoff to rebalance the plane.

In another flight that month, the plane ended up with more passengers than expected, making it too heavy.

While both flights landed safely, aviation commentators and experts say it could have resulted in disaster.

Will Ockenden reports.

WILL OCKENDEN: It was supposed to be a routine flight on the 19th October from Brisbane to Melbourne. But at some point, it dawned upon the Jetstar flight and cabin crew that something was wrong.

After a head count of passengers, it was discovered that 16 more people were on the plane than was thought at take-off, meaning it was 1,300kg heavier than expected.

BEN SANDILANDS: These are really serious investigations.

WILL OCKENDEN: That's Ben Sandilands, an aviation writer and commentator for the crikey.com.au blog, Plane Talking.

He says the other incident, 10 days later on the 29th October, was far more serious.

BEN SANDILANDS: A Jetstar flight to Perth actually really struggled to take off from Melbourne airport at all. It was very nose heavy, clearly had gone too far down the runway to stop and that could have been a very serious incident.

WILL OCKENDEN: The Australian Transport Safety Bureau says it's investigating both incidents to find out how the so-called "aircraft loading event" occurred.

It's classified the incidents as "serious".

Ben Sandilands agrees.

BEN SANDILANDS: They moved people around on the flight so that they could land in the proper configuration in Perth. On the other incident, which was a Brisbane to Melbourne flight, they were out by more than, well, almost two tonnes in the weights and balances on the aircraft and so they had to adjust their landing calculations for Melbourne.

WILL OCKENDEN: They're supposed to do this before they take off. Is there any indication why those checks weren't done?

BEN SANDILANDS: None whatsoever. What is extraordinary and I've been talking to a number of pilots this morning who just cannot believe that something that is fundamental to a small tier country airline service could be messed up so badly by a scheduled airline.

It is beyond belief that an airline in Australia would push back and begin a flight without actually knowing how many people were really on board and indeed the other elements of the calculations as to where they were seated.

That's fundamental. That is the sort of stuff that airlines stopped making a mess of back in the 1950s and 1940s.

WILL OCKENDEN: The Australian Transport Safety Bureau (ATSB) isn't the only one looking into this matter.

The aviation regulator, that's the Civil Aviation Safety Authority, or CASA has taken the unusual step of running its own investigation in parallel to the ATSB.

Peter Gibson is from CASA.

PETER GIBSON: We, of course, as the regulator, as the safety regulator need to look at immediate safety issues, be satisfied that they've been dealt with, that the causal factors have been understood by the airline and that the airline has taken the appropriate actions.

So that's why you've got two parallel investigations.

WILL OCKENDEN: What could be the outcome of a CASA investigation?

PETER GIBSON: Well, we're making sure most importantly that Jetstar is putting in place changes that will ensure these sorts of mistakes aren't made again.

WILL OCKENDEN: Both the aviation regulator and the safety investigator say they are scrutinising Jetstar systems.

Professor Jason Middleton from the School of Aviation at the University of New South Wales says if there's a systemic failure it needs to be fixed.

JASON MIDDLETON: It is a, potentially, a major safety problem because even if the discrepancy is small, the safety problem is, in itself that incident is not a problem, but the system which has allowed there to be an error, if systems are allowed to sort of stay in an error prone fashion then that potentially opens the door to a much bigger problem.

WILL OCKENDEN: A spokesman for Jetstar says the airline is working closely with the ATSB.

The spokesman says since the incidents in October, the airline has already made changes to properly account for the correct loading of passengers and to ensure the aircraft's weight is correct.

KIM LANDERS: Will Ockenden reporting.

Wake up Jeff...err Wazza - sheesh


MTF..P2

P666 - No surprise with this incident. Ever since LCC operations started here in Australia - VA, JQ and TT, there have been myriads of load, weight, out of trim issues reported to CAsA. Many more than in the day of the duopoly of QF and AN. CAsA slapped together a minimal inefficient ground ops team in 2009 from memory, but not enough has been done. I've said for years that it wouldn't surprise me that if one day we have a narrow body accident caused by a load control mistake, 4 tonne ULD not locked down or a general bugger up such as unreported GSE contact with an airframe or a cargo door not properly closed.


The fact that the crew of this flight allegedly had to pull the stick back fully on rotation and knew that she was way out of trim is serious shit. One day it won't get off the ground.



Meanwhile CAsA are too busy pinging pilots for having their caps on crooked, or they are too busy heading to Montreal for 5 star rorts.



TICK TOCK indeed Miniscule

[Kharon]

Safety Loop or Hang-mans Noose?

The Aunty Pru thread – Closing-the Safety-Loop – was among the first to be initialised.  Before the matters discussed were brought to pubic knowledge by Senator David Fawcett (SA) the PAIN associates were researching the official response to recommendations made by the Australian Transport Safety Bureau (ATSB) and coroners related to fatal or serious accidents. The construct was and remains to numerically quantify the amount of recommendations which were positively adopted, those which were dismissed and those which were agreed to, but shelved or acknowledged with none or little follow up action.

The statistics are alarming. In many instances, far too many, basic elements or actual causal factors which may be repeated have been treated in a Cavalier manner; mostly by the authority which has the power to effect changes which would, at very least, minimise the risk of a repeat, preventable fatal accident.

One of the repetitive mores come from the incumbent director of that organisation is, didn’t happen on my watch” which is a euphemism for if a thing happened before his time, the matter will not be addressed; or, Don’t-Wanna-Know (DWK) in parlance.  The intriguing thing is this approach has transmogrified into the approach to ‘things’ that do happen ‘on his watch’.  

Recently a DH 82, Tiger Moth and two lives were lost.  I apologise for directing the reader to links, but to post the report and comment would make this into a very long read.  (One) is the ATSB report and Safety recommendation.  (Two) and (Three) are comment posted.

P9_ “In what we called the ‘maintenance section’ we found a newly dumped Safety Recommendation; from an ATSB report the implications are deep and troubling.  Someone, somewhere should be in trouble.  In short, it's the old story confirming that by using the Australian system for checking if a part is ‘genuine’ it can be demonstrated that a house brick is a fuel pump; don't laugh; it’s been done before.  So another failed safety system is exposed and dumped in the basement along with the other ‘stuff’.  The fact that this ‘oversight’ caused a couple of deaths just don’t seem to disturb the paper hangers working on the showy, shiny outside wall.”

The following extract clearly demonstrates why the ‘safety loop’ has not been closed and presents a classic of the standard response to any recommendation and how responsibility for safety is abrogated.   A very similar situation was researched which occurred in WA where suspect parts were involved in a fatal accident investigation.   The loop was as open then as it is today; there are others.  It is of great concern that the potential for preventable accidents to repeat is allowed to continue.  It is of greater concern the CEO of the Civil Aviation Safety Authority allows the practice of diminishing, then dismissing legitimate Safety Recommendations (SR) from the ATSB.  

Date: 21 January 2016  Safety issue description

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life limits, were appropriately considered.

Action organisation:
Civil Aviation Safety Authority
Date:21 January 2016
Action status:

The ATSB provided the Civil Aviation Safety Authority (CASA) with written information about this safety issue and then followed up with a meeting on 11 February 2015 to discuss the issue. In correspondence following that meeting, CASA advised of the following safety action:

CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised persons and concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.

In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated.

Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue.

ATSB response:

The ATSB acknowledges CASA’s initial action to address this safety issue. However, the ATSB is concerned that this action does not specifically examine the over 1,000 Australian Parts Manufacturer Approvals undertaken by the Regulatory Reform Program Implementation (RRPI) team in 2003. The effect of the policy direction given to the RRPI team, and lack of CASA files containing records of CASA’s engineering assessments of those parts, means there is no assurance that the tie rod manufacturer’s other RPPI-approved APMA parts were not similarly affected by the issues identified with the tie rod replacement parts approval.

In support of this, the ATSB has become aware that at least one other part listed on the tie rod manufacturer’s APMA approved by the RRPI, for the DHC-1 Chipmunk aircraft, is the subject of an airworthiness directive that places a life limitation on the part. Like the APMA for the tie rods, there is no mention of the airworthiness directive, or life limitation, on the associated APMA documents.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:
Civil Aviation Safety Authority

Action number   AO-2013-226-SR-044

Date: 21 January 2016.   Action status:  Released

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life limits.

It’s not that this accident of itself presents a great risk to the ‘general’ public.  The attitude toward closing the loop and preventing repeat of accident is.  This dismissive, arrogance toward any recommendation, be it government, peer, the accident investigator or coroner is a chronic, deeply entrenched malady which seems not to concern the current director, no one jot.

Well, he owns this one now, let’s see how he and his incompetents deal with it.  We shall watch and we shall see.

Toot toot.

[Peetwo]

Skidmore & the continued culture of DWK -

P9 - A very similar situation was researched which occurred in WA where suspect parts were involved in a fatal accident investigation.   The loop was as open then as it is today; there are others.  It is of great concern that the potential for preventable accidents to repeat is allowed to continue.  It is of greater concern the CEO of the Civil Aviation Safety Authority allows the practice of diminishing, then dismissing legitimate Safety Recommendations (SR) from the ATSB.

This was the original ATSB Final Report to which the Ferryman (above) is referring - Cessna Aircraft Company 404, VH-ANV 200303579.

From the 'Significant Factors' section of that report:

1. The material specification contained in the engineering order for replacing the pump

bushing of the engine driven fuel pump (EDFP) fitted to the right engine was not

appropriate.

Strangely there was no mention of this in the 'Safety Action' section of the FR, therefore at that stage it was not considered a 'significant safety issue'. 

However then the Coroners findings were handed down. Extract reference page 16 of PAIN report - Response to Coronial inquiry-Fatal air accidents.:

Coroner Hope.

Relevant Quote: “While the Memorandum of Understanding between CASA and the ATSB
which is currently in effect dated 20 September 2004, only requires CASA to respond to
the ATSB in writing, such response to contain clear statements of acceptance, partial
acceptance or rejection of each recommendation, it is unfortunate that the above CASA
responses do not identify any research conducted by CASA or information obtained,
particularly when CASA has not accepted ATSB recommendations.

The air safety system in Australia depends on interaction between the regulator (CASA)
and the investigator (ASTB). The investigator does not have the power to require that any
safety recommendations be implemented and in that context it is particularly important
that the regulator should respond adequately and appropriately to the recommendations of the investigator.”

Coroner Recommendations.

1. That in future CASA ensure that reasonably comprehensive audits are in fact conducted n respect of all CAR 30 organisations and CAR 35 authorised persons on a regular basis of no more than 24 months duration.

2. That CASA require its CAR 30 design organisations and CAR 35 authorised persons to ensure that engineering orders contain sufficient information in each case to provide a clear indication as to the basis of the engineering order and specify whether the engineering order is proposing a “like for like” replacement or the construction of an
entirely new item. In the event that an engineering order is approving a material change,
the relevant file should contain a metallurgical report providing information in relation to
the material in question.

3. That in the event that CAR 35 authorised persons or CAR 30 design organisations do not prepare engineering orders containing sufficient information, then consideration should be given to not permitting those persons or organisations to continue to exercise those functions...

With the Coroners findings, & with another example of a reconditioned Continental engine fuel pump failure, to the credit of the ATSB they revisited their original VH-ANV investigation and conducted a further investigation in 2005. The ATSB findings were published in report - 200501462:

On 7 April 2005, shortly after the release of the VH-ANV report, the ATSB became aware of the existence of another engineering order, issued by a CAR 35 authorised individual, which provided for the replacement of specific EDFP bearings with an aluminium bronze alloy, similar to that which contributed to the failure of the VHANV pump. In concert with actions by CASA and the ATSB to identify and remove from service any bearings produced to that EO, the ATSB initiated an investigation into the circumstances surrounding the issue of that second EO and the associated material selection processes.

&..

..An inquest into the loss of life resulting from the VH-ANV accident was convened by the State Coroner for Western Australia on 18 April 2005, with the inquest findings delivered in December 2005. As part of its scope, the inquest closely investigated the circumstances surrounding the inception and content of the EO for the fuel pump bearing replacement...

 
This led to the ATSB identifying a 'safety issue' associated with CASA regulatory oversight:

Less definitively, in terms of direct contribution to a reduction in safety, was the frequency and thoroughness of CASA audits undertaken of approved organisations and individuals. The evidence suggests that oversight by a central authority (in this case CASA) is important in ensuring consistency and technical adequacy, with infrequent or shallow audits potentially leading to variability in the quality of engineering outputs.

Now keep in mind that the ATSB report 200501462 was published a decade ago?? Now re-read the CASA response from almost a year ago:

..CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised persons and concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.


In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated...

 
Followed by the CASA SOP - 'sheer bastardry', 'up yours', 'nothing to see here', 'no action required'- response...  

"...Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue..."

Yet again we have a well documented trail of an identified significant safety issue, that has been blatantly ignored & repeatedly obfuscated by our so called 'safety authority' for more than a decade - UFB? Nope true to form...TICK bloody TOCK!


MTF...P2  
 

[Kharon]

If you do nothing else today read -THIS – Grab a coffee and a comfy chair, prepare to enjoy a demonstration of the stark differences between that ‘then’ and this 'now'.  

The link takes you to the ATSB report on an accident involving the beloved Chipmunk. Nah! - Skip the poorly written ATSB twaddle, that is just the usual milk and water pap ATSB seem to produce these days.  Go to the appendices ‘A’ and read a real report from the old days, back when the ‘department’ had pilots who knew their trade and writers who could get the safety message delivered.  

Food for thought, a banquet; not solely for the lessons taught, but a reminder of a trade and craft almost lost; the art of flying.

One loop closed.  RIP Aviation Safety Digest.

Toot toot.

[Peetwo]

Round & round the Mulberry bush -

From the SMH today:

Deadly plane crash reveals old aircraft still flying NSW patients
Date February 15, 2016 - 2:47PM

Rory Callinan


Emergency services at the scene of the plane crash on Canley Vale Road in 2010. Photo: Wolter Peeters

Decades-old light planes using piston engines instead of the safer, more reliable modern turbines are still being used to ferry health department patients around NSW despite a deadly crash involving one of the aircraft.

The father of the pilot who was killed in the Sydney crash in 2010 said he is concerned about some NSW patient transport operations and the performance of Australia's air safety watchdog .

Andrew Wilson, 27, and his nurse passenger Kathy Sheppard, 48, died when the patient transport plane he was flying developed engine problems leading him to shut down one engine and attempt to land on a road at Canley Vale in Sydney's south-west.

Andrew Wilson who died when his patient transfer aircraft crashed in Canley Vale in 2010.

The fully-fuelled aircraft, that was 26-years-old,  slammed into a power pole and exploded during the landing attempt.   Wilson had managed to steer away from a nearby school.

Wilson's father Alan - who has waited years for official investigations to conclude including a 2015 coronial inquest before speaking - remains angry about the findings from the crash investigations and the state of ongoing operations.
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One issue relates to the performance of Australia's Civil Aviation Safety Authority (CASA) which knew two years before the crash that Wilson and 25 other pilots were not qualified to be flying the planes because their training was deficient.

A summary of an investigation report into the crash by the Australian Transport Safety Authority (ATSB) found Wilson had made a series of incorrect decisions in piloting the plane, that had suffered engine trouble just minutes after taking off from Bankstown airport.

But in the full report there is confirmation  that CASA knew two years before the crash that Wilson and the other pilots had not been endorsed to undertake the patient transfer flights in the aircraft. 

The burning plane in which Andrew Wilson and Kathy Sheppard were killed. Photo: Osman Baykurt

And despite knowing that Wilson and 25 other pilots did not have the appropriate training, CASA then failed to ensure he and the other pilots received re-training, according to the ATSB report.

CASA had requested the operator ensure corrective training for the pilots but Wilson and some others never received the training and after the crash three more pilots were found to have not undergone appropriate training.

The ATSB report blamed the failing on the fact there were two companies involved in the operations that had separate air operator certificates and that different CASA inspectors were assigned to the surveillance of each company.


Nurse Kathy Sheppard, 48, who died in the plane crash.

The ATSB said it was unlikely that Wilson's lack of training was a factor in the crash because of his lengthy flying experience in the aircraft.

However Alan Wilson disputes the position. "Had things been done differently Andrew could be alive today," he said.

Mr Wilson is also concerned that piston-engine aircraft are still being used for passenger flights which are contracted  to private companies by the NSW Government.

"A patient being transferred deserves to know that they are going to their destination safely and a piston-engine aircraft is not as safe as a turbine engine," he said.

A NSW Health spokeswoman confirmed that private operators undertaking patient transfer flights in the state were using piston-engine aircraft but said NSW Health required all patient transfer providers and their aircraft comply with CASA regulations.

A spokesman for CASA said there was no reason why piston-engine aircraft could not be used for patient transport work if they were "maintained and operated to the applicable safety standards".

He said it was important to note that the ATSB found it was unlikely deficiencies in the pilot's endorsement training contributed to the crash.

CASA had made significant changes to the way surveillance and safety checks of air operators were conducted, he said.

The spokesman said CASA had taken regulatory action in relation to the companies involved in the operation of Wilson's flight and cancelled their air operator certificates.

MTF..P2

[P1_aka_P1]

Opinion x 2.

I have slightly edited the following which is an extract from a submission provided to the Senate Standing Committee inquiry into Pel-Air.  The Canley Vale accident and subsequent ATSB and CASA management of the case left much to be desired, particularly when a comparison of the ‘differences’ are made.  Part of the submission provided an independent appraisal of the accident and ATSB report which draws attention to the many flaws and much bias.  The ATSB report is, in our opinion, influenced by CASA to the point where we believe an inquiry, similar in nature to the Pel-Air inquiry would reveal another aberration.  Please note CASA were aware of and dismissed this report a full 12 months before the accident.

This report extract is published without prejudice in hope of preventing future accidents which could occur due to flawed safety analysis and reporting.

a) Gentlemen; please be aware that the report presented is "anecdotal", based on information provided to me by the individuals concerned, and from my own investigation into the facts.  It is, to the best of my knowledge accurate.

b) Having held a Chief Pilot approval for almost 25 of the 35 years I have been a professional pilot; and having spent many of those years associated with General Aviation (GA) in that capacity and as Check and Training pilot, I feel obliged to bring the following reports to your attention.  Had, as I initially believed, the reports were "Pilot gossip" or "Junior pilot speak" I would not have taken the trouble of writing and editing this report.  I have attempted to recreate the spirit, intent, humour and manner in which the information was delivered.  Although there is nothing remotely humorous here.

c) Regrettably, this is not so. I cannot, in good conscience, allow the existing situation to continue.  It is inevitable that sooner or later, the current Sky Master operating standards are going to be the root cause of an accident or serious incident.

d) I accept that on an individual basis the items may seem, at first glance, trivial. However, Individually, each item provides concern, collectively, I believe there is real cause for alarm.

Preamble.
a) The holes in that famous cheese are slowly, but inevitably lining up.   It is no longer a matter of if there will be an accident, but when.  

b) For the record, one day (or night) a junior pilot is going to get trapped in bad weather, or bad situation.  The procedures and methodology employed to mitigate risk will be directly reflected by the end result.  

c) I have noted that a lack of respect within the pilot body for the edicts of the individual mentioned has had a serious, negative impact on SOP.  Essentially this individual has lost control of the pilot body.

d) The pilots are, to all intents and purposes, now "making it up" as they go along in the absence of creditable guidance .  They are informing each other, through the "drums" of how they do things. SOP is circumvented, replaced by normalised deviance.    

e) Some of the junior pilots will (i) do exactly as they are told, to impress and (ii) are highly susceptible to "senior" pilot influence, for right or wrong.

f) The amount of time and money wasted are serious.  For example, ESIR pilots are arbitrarily grounded, no remedial training is offered and then a "Check flight" is conducted.   There have been 4 events this week.   Serious ESIR require deep briefing and training; but for minor infractions, a "chat" would achieve a far more useful outcome than an aircraft and pilots out of the system for a period of time.

1) Hand slapping.
a) I have now been informed by three individual company pilots that their hands have been slapped during "training" operations, conducted by the XXXX.

b) Quite apart from the legal aspects of "assaulting" and interfering with a pilot in flight.   The humiliation of being treated like a 3 year old and the potential for distraction both physical and mental during a critical flight period is dangerous. The practice is not an approved (or documented) training procedure.

c) The most alarming thing is, I believe that the events are occurring during landing, which in itself is alarming, however, the reasons for the procedure are even more so. Pilots are "slapped" for maintaining contact with the throttles during the last 50 feet of a landing.   They are instructed to close the throttles at 50 and await contact with runway.

d) Recently a very Junior pilot was instructed to ensure that every landing was made on the "piano keys", literally at the very beginning of the runway.  He is the only pilot to be so instructed.  During the tirade against his poor landing technique, he was also informed that "Navajo fuel gauges are 100% accurate, all of the time".

f) I have been reliably informed that pilots are "slapped" for placing the propeller levers at "Climb" RPM prior to landing.   In short, the aircraft is not being configured, as per the AFM checklist for a missed approach.

g) I will not elaborate here the sheer, purblind folly of these practices, the disregard for AFM procedures or the requirements of sensible operating practice.   This has all been demonstrated, with serious consequences, on several occasions in the past.

2) Unsafe practices.

a) I have personally heard once, and been informed several times of pilots being instructed to perform operations in a manner which defies most of the sensible and legitimate tenets of sound practice.

b) The most recent was a serious lecture, given, thankfully, post flight to one of the most sensible, intelligent pilots we have on staff.   The pilot requested a meeting with me and, told me of the event.  It is one of three similar stories.

c) In short; the pilot was tasked to Lismore NSW, after a second attempt at the instrument approach, the aircraft was visual at the minima, but, on top of a very low deck of Stratus (lifting fog) which obscured the aerodrome and prevented a landing.  The aircraft was diverted to Ballina.

d) This individual later responded to a general question related to the days operation with a sketch of the days events.  He was then taken aside and briefed on how it should be done, not to labour the issue the essential points where:-

(i) Slow the aircraft (PA 31-350) to less than 120 knots,
(ii) Stooge about until you identify a roadway which leads toward the aerodrome,
(iii) Get below the cloud and follow the road through the hills until the runway is sighted.   Enough said.

3) Fuel system questions.

a) Apparently, during a supposed "check flight", pilots have been seriously chastised (not slapped) because, they had no idea that PA 31 series aircraft engines could, (despite AFM prohibition), be cross fed whilst both engines are operational.

(i) The question runs like this, " OK mate, you look out of the window and notice fuel leaking (how ??) from the right main (which "main" tank is a mystery).    Question ?.   How can you recover (and use) this fuel.  
b) The sensible answer is land at the nearest suitable.   WRONG !!. (Hand smack following).

c) The right answer, apparently, is some unbelievable rubbish, not related to the actual fuel system, by which, despite the manufacturer AFM warnings, this can be achieved.

d) When a sensible pilot was asked this question, he diplomatically ventured the idea that if fuel was sighted, then the leak is severe, and the source indefinable.  The best answer is to close down the engine, and land at the nearest suitable, (engine and/or wing fires etc).  WRONG !!.

e) When the pilot produced a fuel schematic and illustrated why the manufacturer disallowed the practice, and further pointed out the complex series of circuits to be managed (from the aircraft schematic) and stated that all control was behind the cross feed line, only then, reluctantly, was it was acknowledged that, well perhaps the question "could" be rephrased; but it is still achievable.  QED.

f) Could be !.   Could be a junior pilot, in trouble one day does exactly what the correct answer is (according to the "training pilot") and bursts into flames, 10, 000 feet above a suitable airport).

4) Engine Failure.

a) Currently under investigation (CASA/ATSB) is a series of turbo charger failures, traced to a manufacturing fault.

b) What is not being examined is the inconsistent response and the total absence of any training material, course or general discussion relating to the incidents.  There have been at least eight (8) return to land and a couple of unscheduled occurrences.

c) The unbelievable part is that despite correct technique and, a couple of very level headed decisions being made, several pilots have been the recipient of a serious dressing down, for doing the right thing.  I know this because, it's usually me that gets asked the questions afterwards, by confused, offended pilots.

d) On one occasion, a LAME pilot had a partial failure on take off with a full load of passengers.   During the verifying procedure it was noted that when the throttle was retarded, the yaw increased.   He surmised that by not securing the engine, and leaning the mixture, he could retain 60% power on the engine.  The return to land was made safely.  The pilot almost resigned after being told that he was "basically useless".

5) Check flights.

a) The most recent horror story occurred very recently.  It is the latest in a long litany of similar events.  Please keep in mind the following points.

(i) this occurred during a commercial operation, with a flight nurse and patient in the back.

(ii) the 'check' pilot has no formal training or qualification to act as either a training pilot or check airman.

(iii) the pilot involved is a 'journey man' pilot, although well respected and capable, for the experience level.

b) The pilot was informed that there was to be a "Check flight" to qualify him to conduct patient transport operations.   There is no formal statement in the Operations Manual relating to this, no formal training procedure set down and no "pass/fail' benchmarks.

c) Pre flight the pilot was asked if he could conduct a DGA approach, the correct answer was offered.  WRONG.  The check pilot clearly has some confused ideas about the use of GPS as DME.

d) The pre take off (ground time) for briefing with engines running was spent in a lecture, delivered by the "Check pilot" of approximately a 30 minutes.  The talk went on during runway entry, take off clearance delivery, line up and take off role, ("non stop natter") the pilot, distracted, in an unfamiliar aircraft type omitted to turn the transponder on.  

e) The route was KAT – ORG, at top of descent the pilot still being chastised for the transponder, was instructed to conduct a DGA arrival.   Half way through the GPS was turned OFF, the pilot was informed that he was a fool, acting illegally and told to overshoot (despite being visual) and join the NDB approach.  No problem until an opposite direction Citation informed them that he was entering the overshoot procedure and was climbing to holding altitude.

(i) Imagine, the radio is taken over, there is no distance guidance and suddenly you need to find 1000 feet to avoid a mid air, no clear briefing, no instruction and absolutely no idea of who has command of the flight.

f) The remainder of the flight was similar, no clear definition of whether it was training or checking.  Needless to say the kid has been completely grounded, severely chastised and is completely demoralised.

g) The number of real live serious safety issues raised in this matter alone should at least be grounds for CASA investigation.  This gentleman should not be allowed to conduct training or checking until he has at least a rough ides of how to set about the task safely and consistently.

6) Maintenance Issues.

a) I have now confirmed that XXXX has, on two occasions, failed to report aircraft un serviceability's.

b) On one occasion, the follow on pilot grounded the aircraft, pre departure, recorded 10 separate items, of which 4 were MEL covered, but not noted.   The previous pilot had completed 5 sectors, one of which was a purported "line check + ICUS", services were all commercial, over approximately 7 hours of flying.  The aircraft was returned to and signed off as being serviceable.

7) Useable Fuel.

a) Two individual pilots report that the flight planning data for the PA 31 series aircraft has been altered to reflect that the capacity (fuel calibration card) indicated for each individual aircraft has now become the fuel useable for flight planning.  

b) Insanity, when it was pointed out that the AFM is clear and specific as to the amount of useable fuel, the CP then declared that engineering had incorrectly conducted the calibration checks and it was still acceptable to plan a flight against the placard capacity.  CAO 108 was referred to, it took a meeting of the GM, HAM and CE to attempt a correction.  To date, the flight planning data still reflects the total capacity as useable fuel.

c) This is as good an indication of absolute incompetence as I have ever witnessed.   A few seconds of thought produces several lethal practices and identifies complete and utter incompetence.


8) A last word.
a) Lately, simulating engine failure has become part of the regime, the latest was, as usual not briefed, and conducted at Tumut with a junior pilot at the controls, at high speed during the take off roll.  

Just slightly short of criminal.   What next I wonder.

There is, as you can imagine, a lot more contained within the report.  PAIN believes that the family and friends of both Kathy and Andrew deserve the very best from the aviation oversight organisations.