[Peetwo]

Reference post -

Four incidents, a ditching & two cover-ups? - Safety risk mitigation Oz style.

Spot the disconnect - Part ??
Bizarrely even the ATSB twitter person missed this??? However last week the bureau put out the following presser (that was associated with this serious incident - report AO-2012-073):
  

Handling unexpected developments


A recent ATSB investigation shows how unexpected developments or confusion about procedures can contribute to decisions and actions that increase the safety risk to the aircraft.

In the incident, the crew of a Cobham Airline Services Boeing 717 aircraft, was conducting an instrument approach to land on runway 03 at Perth Airport.


The aircraft was conducting an approach in instrument meteorological conditions after a flight from Paraburdoo, Western Australia. When they reached the decision altitude, the crew initiated a missed approach procedure as they had not obtained visual reference with the runway.


Almost immediately, however, they obtained visual reference with the runway, discontinued the missed approach procedure and landed, despite the aircraft being in an unstable condition.


The ATSB found that the onset of fog at Perth Airport at the estimated time of arrival was not forecast until after the aircraft had passed the point in the flight when it had insufficient fuel remaining to divert to a suitable alternate aerodrome. Before that point, there had been no requirement for the aircraft to carry fuel to continue to a suitable alternate.


Under the circumstances, the flight crew considered that the better option was to discontinue the missed approach procedure and land, in spite of the aircraft being in an unstable condition due to the initiation of the missed approach.


This incident highlights the risk of an unstable approach from not following a missed approach through to its conclusion.


Unstable approaches are a frequent factor in approach and landing accidents, including controlled flight into terrain. The Flight Safety Foundation has developed an Approach and Landing Accident Reduction Tool Kit to reduce the risk of approach and landing accidents.


‘Handling approach to land’ is also a top safety concern in the ATSB’s SafetyWatch initiative. The ATSB has identified an increasing trend where pilots mishandle or mismanage their aircraft and flight profile when unexpected events arise during the approach to land.


The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.

However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts.


Read the investigation report AO-2012-073
 








Last update 25 February 2016

This is an extract of the findings:

From the evidence available, the following findings are made with respect to the weather-related operational event involving a Boeing 717, registered VH-NXO, which occurred at Perth Airport on 1 June 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual.


Contributing factors

• The weather forecast for Perth Airport was amended to include the requirement to carry sufficient fuel to divert to a suitable alternate aerodrome when the aircraft no longer had that amount of fuel remaining.
  
  
• The captain, as the flying pilot, continued an approach to land after the approach had been destabilised by initiating a go-around procedure.
  
  
  

Other factors that increased risk

• The flight crew did not update the weather forecast for Perth Airport en route which, although in this instance did not indicate an operational requirement, was a missed opportunity to update pertinent operational information prior to the aircraft being committed to its destination.
  
  
  

Other findings

• Given the circumstances, when confronted by a choice between completing the missed approach with an indeterminate outcome and landing from a discontinued missed approach, the captain chose the option that was considered to represent lower risk.
  
  
• The operator’s procedures in the case of an unstabilised approach were unambiguous and reflected those promoted by the Flight Safety Foundation.
  
  

Now according to the investigation page the Final Report for AO-2012-073 was published on the 12 October 2015, i.e. 3 years 4 months & 12 days after the incident occurred; no surprises there I guess??

However what I do find absolutely unforgivable was this incident, with some very real comparisons to the Mildura Fog Duck-up..

"..The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.

However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts..."

..was still being investigated after Mildura occurred and in parallel with that investigation and yet it does not even rate a mention - UFB!


MTF..P2

[Kharon]

A Sunday rant. (My turn).

This report –HERE - Absolutely overdue and most definitely obfuscated.  Don’t read the fluffy ‘abridged’ version, download the whole disgusting thing for the full nauseating effect.

Well Senator Sterle; I’ll see your 42 tons and raise you 49 tons.  The differences are worthy of comment.  Our 49 tons was doing about 280kph approaching the ‘bridge’, it cannot be reversed, nor can it be decoupled; it also had many of your fellow West Australians inboard. Had it 'jack-knifed', there is no friendly RTA to sort out the mess; only fire engines, police and ambulances initially, coroners and inquiry later.  

This nasty, grubby little report from the ATSB, for what they seem to find a cut and dried matter, has been three years in the making.  It is a grubby attempt to distract the reader away from several core issues which are not even paid the courtesy of being obfuscated; they are simply ignored.  

No calculator required for the simple mathematics.  Using the index finger of your right hand, count the fingers on your left hand – Norfolk (1) Mildura (2) Mildura (3) Perth (4).  Four known close calls all with several things in common, short of fuel and rapidly changing weather, three ending happily on runways, one ditched in open water.  

The common threads are easily discerned,but even this latest pathetic report tries to hint at pilot error.  It is a good thing that the ATSB do not apportion blame; but they do hint at it.  Why?, well, another common factor is the sacred cow of the BoM, who only need to be within +/-70% accuracy of actual in their forecast (from memory) to be off the hook.  This level of accuracy has little intrinsic or practical value to a pilot.  In court the responsibility will all fall to the pilot, everyone else has wriggle room and bolt holes, all except the poor mutt in the dock.  

ATSB, ASA, BoM and CASA need to resolve this situation; we now have escaped four times from disaster where bad weather and low fuel reserves have been intricately bound with poor, late weather forecast.  It’s a trend and ATSB should be screaming from the roof tops, demanding something be done to reverse that trend.  Do they? No sir, they do not.  We get presented with a snide, trite, puerile little report which tries to shift the spotlight off the piss poor service to the travelling public delivered by our expensive ‘safety watchdogs’.    

When planning for the return flight at Paraburdoo, the Perth aerodrome forecast (TAF) and the trend forecast (TTF) did not contain any forecast operational requirements for this aircraft to carry sufficient fuel to fly to an alternate aerodrome. At 2300, 5 minutes after take-off, the Perth TTF changed with the forecast onset of fog 65 minutes after the estimated time of arrival (ETA).

Snipe 1: perhaps on the basis of the new forecast the aircraft should have landed and uploaded more fuel, then tried again?  Bollocks.

At 0010, which was about the time when the aircraft commenced its descent and shortly before the aircraft no longer had sufficient fuel to divert safely to a suitable landing aerodrome, the Perth TAF was amended to indicate a requirement for the carriage of sufficient fuel to divert to an alternate airport on the basis of more than four OKTAS8 of cloud with a base below the alternate minimum of 700 ft above the aerodrome reference point. The forecast also predicted that 35 minutes after the aircraft’s ETA, there was a 30 per cent probability of fog reducing the visibility to 300 m, which was below both the alternate and landing minimums for runway 03.

Snipe 2: Neatly blurred; the implication is that somehow it’s the pilots fault that there is insufficient fuel.  There is little point (other than spite) to be mentioning any of the above; they were dead set legal and righteous to continue and had adequate fuel to complete the task as scripted on the weather forecast as applicable to the time; not the clucking future but right there and then.

Soon after, at 0014, a TTF SPECI9 was issued for Perth Airport indicating that the visibility had reduced to 7,000 m and the airport was partially covered in fog. The observed visibility, as reported on the TTF SPECI issued at 0030, which was soon after the aircraft’s landing time, was 900 m in fog.

Snipe 3:16 minutes from touch down, visibility 7000 meters partial fog – so what, still all good. Continue on; the nasty bit is the statement “soon after” etc.  This implies the landing was in ‘marginal’ (borderline illegal) conditions.  

When you break down the time line, you realise that this flight was always legal, the only ‘indiscretion’ was a conflict with company procedure.  The decision to land off the go around was righteous, given the circumstances.  ATSB would prefer you believed otherwise, they just hint at it though.    Pure spite and malice. 

During the flight, the flight crew did not seek or obtain an amended or updated forecast for Perth.

2255 – Take off.  Time en-route 90 minutes - ETA Perth 0130.

2300 – amended forecast for Fog at 1 hr 05 minutes after ETA.  Fog @ 0235.

0010 – Top of Descent (TOD).  Forecast amended to reflect a 30% chance of low visibility 35 minutes after landing; fog forecast from 0205.  

0014 -  Special weather visibility 7000 meters.

0030 visibility 900 meters.  AFTER LANDING...... FFS.  What's your point?

The captain reported that he normally obtained the latest TTF for Perth when overflying the automatic en route information service (AERIS) at Meekatharra, about 360 NM (667 km) north-north-east of Perth.

However, the timing of the flight and the delay normally encountered in updating the available weather information on the AERIS meant that he did not expect to obtain the latest TTF at that time.

When the aircraft was about 240 NM (440 km) from Perth, the crew obtained the latest automatic terminal information service (ATIS) weather observation for Perth, which provided no indication of deteriorating weather.

Routine, bog standard, sensible operating practice.  The rules and the BoM failed the public yet again, with everyone off the hook except those burned alive.  It is high time the ATSB started bringing this trend into focus instead of drafting a carefully prepared, prejudicial statement for prosecution use.

The Beyond all Reason methodology and those that espouse it are not only becoming an international embarrassment, but part of the causal chain.

There you go Glen; my little Sunday rant; and yes, I feel better now.

Toot toot.

[Peetwo]

Blind Freddy could join these dots -

Following on from the excellent "K" Sunday rant, I note that Senator Xenophon has a QON that is very much related to the 16+ year continuously obfuscated safety issue:

QON 192 - Senator XENOPHON: I go to the issue of the 22 February 2000 Bureau of Meteorology report about the reliability of Norfolk Island forecasts. Did your first report and does the subsequent report that you have been asked to do in relation to the Pelair incident take into account the fact that those matters do not appear to have been followed through by other agencies in terms of the lack of reliability on the Norfolk Island weather forecasts?


Mr Dolan: Mr Walsh is supervising the reopened investigation.


Mr Walsh: Can I clarify the question. Are we looking at the reliability or are we looking—


Senator XENOPHON: No, there was a report issued on 22 February 2000 about the reliability of Norfolk Island forecasts. It appears that certain things were not followed through. I would like to put it to your agency that it appears that down the chain there were things that were not followed through as a result of the very clear report on the lack of reliability. Was that something that was taken into account with respect of the first investigation report on the Pelair incident and also now with the second report that is being considered?


Mr Walsh: I cannot speak to the first investigation because I was not involved. In the second one, I would have to actually take it on notice.

Senator XENOPHON: Perhaps you could take that on notice in relation to the first report. I go now to the issue of the LAHSO operations. There is a report being undertaken in respect of the 5 July incident 2015. Do you have an approximate time line of when that report will be completed? 

However we may finally have some progress on possibly proactively addressing a safety issue that was identified 16 odd years ago and then again some six + years ago in the ATSB PelAir preliminary report.
The following is an excerpt from the February CASA Briefing:

Changes proposed to fuel rules

An update is proposed for the regulatory requirements for carrying sufficient fuel and oil on aircraft.  Comments are being sought on a package of proposals to change the fuel and oil regulations, introduce a new legislative instrument and revise a civil aviation advisory publication.  CASA is proposing the changes following revised international fuel practices and policies from the International Civil Aviation Organization, along with Australian Transport Safety Bureau research into fuel related occurrences.  The proposal is to repeal the existing set of fuel and oil regulations and to create separate regulatory sets for fuel and oil.  Until the new operational Parts of the Civil Aviation Safety Regulation become effective, these provisions would be contained in 234 and 234A of the Civil Aviation Regulations.  A new instrument would then prescribe the fuel-related requirements - setting out mandatory fixed fuel reserve and variable fuel reserve quantities, closely based on the current guidelines.  The instrument would also cover matters to be considered when determining if an aircraft is carrying sufficient fuel, the amounts of fuel to be carried, the procedures for monitoring fuel quantity during a flight and the procedures to be followed if fuel reaches a specified lower limit during a flight. 

In addition, the proposed instrument would introduce minor amendments to the existing fuel regulations, mandating a variable fuel reserve of at least five minutes on short duration charter and regular public transport flights.  The instrument would cover fuel requirements for pressurisation and engine failures and introduce additional fuel requirements.  CASA has sought to balance the operational, cost and environmental requirements to reduce unnecessary fuel uplift without compromising safety.

Find out more about the fuel proposals and comment before 16 March 2016.

  
This bit..
"..CASA is proposing the changes following revised international fuel practices and policies from the International Civil Aviation Organization, along with Australian Transport Safety Bureau research into fuel related occurrences..."

...what a load of bollocks

So will this proposed CASA action actually address the issue of the reliability of BOM forecasts?

From the AO-2012-073 final report...

"...The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.

However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts..."

...and from the contributing factors section...

"...The weather forecast for Perth Airport was amended to include the requirement to carry sufficient fuel to divert to a suitable alternate aerodrome when the aircraft no longer had that amount of fuel remaining..."


 ...I would say not even close, all it will do is yet again slate the blame 100% on the PIC -

MTF...P2

[Peetwo]

'Just blame the Pilot' - Part II


Continuing on the theme (above) the following is off the excellent blog site the Inner Art of Airmanship Blog and examines why it is sometimes easier to 'just blame the pilot' rather than address the deeper, systemic organisational safety issues..

Blame the pilots?

By Dave English
Air Force Times article from two days ago sums up the results of a six-week investigation of the October 3rd bombing of a Doctors Without Borders hospital in Afghanistan that killed 30 people – Crew Blamed.


[/url]
However the news story also notes deeper systematic issues, a culture that places pilots into impossible situations. But you can’t discipline a procedure or a rule or a culture. And no general is going to fall on his sword when there are crew that can be blamed for their ‘human error’.

 “The direct result of human error, compounded by systems and procedural failures.”

Army General John Campbell,
Top U.S. commander in Afghanistan.

The news story lists worrying items including:

• U.S. special operations commander “lacked the authority to direct the aircrew to engage the facility”.
  
• The AC-130 aircraft that fired on the hospital had launched urgently in response to a report of troops under fire. As a result, the crew did not conduct a normal mission brief nor obtain “crucial mission essential related materials” that would include the “no-strike” list identifying the location of the hospital as being off limits.
  
• During the flight, the aircraft’s onboard electronic systems malfunctioned, resulting in a breakdown of some essential command and control capability, such as eliminating the aircraft’s ability to transmit video, and send and receive email.
  
• In the air over Kunduz, the aircraft conducted an evasive maneuver that forced it to move “away from its normal orbit … this degraded the accuracy of certain targeting systems which later contributed to the misidentification of the MSF trauma center”.
  
• When the targeting systems malfunctioned, the AC-130 aircrew “visually located the closest, largest building” and found that it “roughly matched” the physical description of the building that U.S. SOF commanders said was the proper target. “At night, the aircrew was unable to identify any signs of the hospital’s protected status”.
  
• About one minute before the aircraft began firing on the hospital and despite the breakdown in some of the aircraft’s communications systems, the aircrew transmitted to their operational headquarters at Bagram Airfield the coordinates for the MSF trauma center as their target. The headquarters had access to the no-strike list, which included the hospital, but did not realize that the grid coordinates for the target matched a location on the no-strike list or that the aircrew was preparing to fire on the hospital.
  
• The aircrew continued repeated strikes on the hospital target despite telling investigators that they did not observe hostile activity at the MSF trauma center.
  
• During the 29-minute assault on the hospital, the aircraft’s targeting system began functioning correctly and identified the correct target, but “the crew remained fixated on the physical description of the facility” and disregarded the grid coordinates.
  
• Twelve minutes after the assault on the hospital began, U.S. operations forces received a call from MSF saying the hospital was under attack. But that information was not relayed to the aircrew before the AC-130 had completed its strike and departed the area.
  
  Who reads all that, and thinks the first thing we should do is blame the gunship operators?
  
  We’ve seen all this before. In 1994 two USAF F-15’s shot down US Black
  Hawk helicopters over Northern Iraq in a friendly fire accident. 
  
  The F-15 pilots were faulted for misidentifying the helicopters as hostile. It’s commonly referred to as the [url=https://en.wikipedia.org/wiki/1994_Black_Hawk_shootdown_incident]Black Hawk Incident (Wikipedia page). It was the basis of an outstanding book by Scott Snook titled Friendly Fire. The book, taking a lead from Perrow’s Normal Accident paradigm uses systems theory and organizational behavior to show how such accidents can, and will, happen. We can do things to prevent them from happening, but they are at the system level not the blame the pilot level. Resilient organizations learn to absorb human errors and other disturbances, and still move forward.
  
  At the pilot level, what can we do to lesson the chance of being caught in a Normal Accident, a system fault? Well, it’s tricky! But be prepared to push back against rushing. Be prepared to be known as a PITA (Pain In The Arse) that writes up conflicting organizational policies and procedures. Question authority.
  
  Learn your job, and the jobs of others you interact with, as fully as you can. And good luck! Because the organization will never fail to find a scapegoat: Blame the crew.
  
  
  
  

MTF...P2

[Kharon]

From Ben Sandilands blog  - Plane Talking, on Crikey:-

Nothing can excuse the Albury Virgin ATR safety fiasco, not even this latest piece of ATSB fluff.

The rest of the article – HERE – is worthy of consideration and discussion.

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ ~ ~

Mountains to Molehills – ATSB style.

When this ‘incident’ first came to light there were serious questions raised, to which ATSB has not deigned to investigate or answer.  The aftermath – 13 passenger flights – are not the aberration, but a resultant of the first in a series of events which remain firmly ignored, unmentioned and; not, as yet addressed.  

In short; the root cause of the initial ‘problem’ remains unresolved.  The ATR has a facility which allows the two normally interconnected flight control systems (yokes) to be disconnected and operate independently.  This in case a manual flight control channel is lost.  With a significant amount of opposite direction pressure from the other yoke, (e.g. one pulls up, ‘tuther pushes down) the two flight control systems may be separated.  This event occurred during a ‘routine’ descent to approach at Sydney, with no noted flight control problem.  The potential for stress and damage caused by opposing control inputs, from two viable systems should have engineering alarm bells ringing, demanding serious, in depth inspection.  It did not.  The controls were simply reconnected, a cursory inspection conducted and the aircraft returned to service; for the remaining 13 flights.

In other accident events ATSB have played the accompaniment to the CASA preconceived notion, Canley Vale and Pel-Air for example.  Where ATSB report supported a stern, rapid prosecution of pilots and operators, through to Coroners court, where required.  There are some very serious incidents still on the books at the moment related to turbo-prop powered aircraft – Moranbah and the Newcastle coal loader incident for example; there are some serious, outstanding heavy jet transport incidents, such as Perth and Mildura which are still patiently awaiting their ATSB final report.

If we are serious about ‘safety’ the minister, the government and travelling public need to get over the bi-partisan system of relying on ATSB and CASA to ‘sort it’ and start demanding changes to the way our ‘aviation watchdogs’ set about doing their expensive business.  But, enough said.   All been said before, and precious little changes.  But gods help the government in power when the unthinkable happens and a Royal Commission is demanded.

The time is now, to get our aviation safety house in order, before we run out of dumb luck.

Toot toot.

When 'Darren' is standing looking down into a smoking hole, filled with body parts, will he have a hair out place then? - Big money say not.

Thanks P7, my shout; soon.

[Peetwo]

From Ben Sandilands blog  - Plane Talking, on Crikey:-

Nothing can excuse the Albury Virgin ATR safety fiasco, not even this latest piece of ATSB fluff.

Where  the T-tail on Virgin ATR was seriously broken, but kept flying

...Now we have a new minister, Darren Chester, and it is too early to determine whether he does what his department tells him to do, or even asks whether it tells him what he really should be told.


The ATSB initially buried the matter in its weekly review. But based on what the ATSB released in June and what a genuinely deeply concerned Virgin Australia said and briefed, respectively, at that time, this is what Plane Talking then posted:

The core elements of the ATSB report show that Virgin Australia’s engineering contractor and the airline failed to identify and understand serious damage done to this aircraft in the turbulence event.


The aircraft was then allowed to carry passengers for thirteen sectors in that state before an in-flight crisis five days later approaching Albury from Sydney where it was grounded [for months until repaired enough to be flown away for more repairs.]


These are scandalous disclosures.  No one in the general flying public in this country expects that a contract maintenance organisation could be so bad at its job that it failed to understand and identify the grave safety of flight issues apparent on the Virgin turbo-prop on 20 February.


It is after all, what the maintenance provider is paid by Virgin to do, rather than scratch their heads and release the aircraft back into service.


It’s Virgin’s inescapable legal obligation to ensure that all aircraft are safe before flying. It didn’t ensure the safety of these 13 flights. It’s CASA’s role to enforce and maintain a safe level of oversight on airline operations and ensure that those who carry out aircraft maintenance are competent and effective.

It’s the Minister’s responsibility, to make sure that rural and regional air services, including those that fly him and his colleagues to and from Canberra, are safe. It’s called Ministerial responsibility.

How on earth did this situation arise with this aircraft, and what steps have been taken to ensure that whoever screwed up so badly, within Virgin, and within the contractor, never get to imperil the safety of flight in this country in this manner again?

This may seem harsh. But flight safety standards are by necessity harsh. The harsh reality is that 13 passenger loads were exposed to a broken aircraft, and that is intolerable. Read the ATSB document linked to above very carefully, as it contains inferences and disclosures that are very disturbing...

The rest of the article – HERE – is worthy of consideration and discussion.

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~ ~ ~ ~

Mountains to Molehills – ATSB style.

When this ‘incident’ first came to light there were serious questions raised, to which ATSB has not deigned to investigate or answer.  The aftermath – 13 passenger flights – are not the aberration, but a resultant of the first in a series of events which remain firmly ignored, unmentioned and; not, as yet addressed.  

In short; the root cause of the initial ‘problem’ remains unresolved.  The ATR has a facility which allows the two normally interconnected flight control systems (yokes) to be disconnected and operate independently.  This in case a manual flight control channel is lost.  With a significant amount of opposite direction pressure from the other yoke, (e.g. one pulls up, ‘tuther pushes down) the two flight control systems may be separated.  This event occurred during a ‘routine’ descent to approach at Sydney, with no noted flight control problem.  The potential for stress and damage caused by opposing control inputs, from two viable systems should have engineering alarm bells ringing, demanding serious, in depth inspection.  It did not.  The controls were simply reconnected, a cursory inspection conducted and the aircraft returned to service; for the remaining 13 flights.

In other accident events ATSB have played the accompaniment to the CASA preconceived notion, Canley Vale and Pel-Air for example.  Where ATSB report supported a stern, rapid prosecution of pilots and operators, through to Coroners court, where required.  There are some very serious incidents still on the books at the moment related to turbo-prop powered aircraft – Moranbah and the Newcastle coal loader incident for example; there are some serious, outstanding heavy jet transport incidents, such as Perth and Mildura which are still patiently awaiting their ATSB final report.

If we are serious about ‘safety’ the minister, the government and travelling public need to get over the bi-partisan system of relying on ATSB and CASA to ‘sort it’ and start demanding changes to the way our ‘aviation watchdogs’ set about doing their expensive business.  But, enough said.   All been said before, and precious little changes.  But gods help the government in power when the unthinkable happens and a Royal Commission is demanded.

The time is now, to get our aviation safety house in order, before we run out of dumb luck.

Toot toot.

When 'Darren' is standing looking down into a smoking hole, filled with body parts, will he have a hair out place then? - Big money say not.

Thanks P7, my shout; soon.

[P7_TOM]

Fluff and nonsense, my opinion.

My turn.  Is it just me? While happy to have the latest ATSB report and some 'facts' to consider, the wording of the ATR investigation seems a bit – 'twee', (for the wont of better), fluffy or something:- The first five paragraphs are totally and utterly irrelevant.  Except  “20/02/14 VH-FVR departed schedule Sydney – Canberra – Sydney.”  That's a full page of fluff to say routine operations out of Canberra and until mid descent Sydney.  So, why bother with the 'twaddle'?

Much later in the 'report' (after more fluff) we get the high drama scenario of a runway change; 16 R to 16 L – then the information that – surprise, surprise, - the Seat belt sign was on and the checklist was almost complete.  Anything of any great value so far?  Nope - and we are now up paragraph 10. This is where the FO started the descent – on AP.  Wow! invaluable, that's way cool.  Are you not diverted? Ah, but wait – now we come to it.

ATSB – “At 1640 and about 8,500 ft, the crew noticed the airspeed going up quickly and the speed trend excessively high. The first officer reduced engine power and used touch control steering to temporarily disconnect the autopilot before manually raising the nose to control the speed. The aircraft felt ‘heavy’, requiring the first officer’s two hands on the controls to move from the then -4° pitch angle (aircraft nose-up/down). The first officer expected that the pitch correction would be sufficient to arrest the speed trend.”

Alternate version – T firmly IC from Fearless......

The Australian Transport Safety Bureau, an equal opportunity employer, has revealed that at 1640 and about 8,500 ft, the crew noticed the airspeed going up quickly and the speed trend excessively high. Beads of sweat poured off the first officer as she clawed at the throttles to reduce engine power and use touch control steering to temporarily disconnect the shattered autopilot before straining desperately to lift the leaden nose and prevent the doomed plane and its terrified passengers plummeting to disaster. The aircraft felt ‘heavy’, requiring the first officer’s two hands on the controls to move from the then -4° pitch angle (aircraft nose-up/down). The first officer gambled that the pitch correction would be sufficient to prevent the mortally damaged plane from smashing through the dreaded sound barrier.

Deconstruct the ATSB paragraph, I'll give you a start – airspeed "going up quickly"; they were 235 KIAS, top speed 250 KIAS.  Do ATSB define time line, distance to run, actual ROD v required, TOAT, wind profile, temperature profile, inversion layer; or, sheer line, reported updraft, CAT; or stable mountain wave; or even a suspect trim fault. No, they do not.   But we do get "airspeed going up quickly" which is just 'fluff'.   Anyway SOP – power off – trim up – two hands: - no fix?– why not?.   Big question.  Was the auto trim running against the FO input?, had the skipper got his boot braced against the prong?  This is a definitive moment and the best we get is "speed going up quickly". Nonsense ATSB, stuff, fluff and nonsense.

ATSB “The captain was unsure if the first officer’s control inputs were sufficient to avoid an over-speed so put one of his hands on the controls and disconnected the autopilot to raise the nose further.”

WTF - Did the Capt. call 'taking over' Y/N ?  The Who’s on first, What’s on second etc. show for the next three paragraphs. Somewhere in that melee the elevator channels were split.  There is no record of this being executed as a conscious, viable option; somehow there has been a physical, opposite directions force applied to ‘split’ that system.  I forget the figure; (26 Kg pops to mind, but don’t quote it), this coincident to a 3g control event and warning lamps.  I believe we need to know exactly what was occurring on that flight deck; warts and all.

Then; 'the' paragraph worthy of a channel 7 headline, just before an advertisement break :-

ATSB – “To both crew members, what happened next was unexpected and unclear.”

High drama indeed....

ATSB - “Suddenly, the crew felt high positive g,[3] the controls felt different and spongy, and cockpit warnings activated.”

Somewhere, as yet undefined, between TOD, the "suddenly" moment and stable @ 230 KIAS the elevator channels managed to ‘split’ and despite previous "heavy" and "spongy" feeling controls – "suddenly" all is well, except for some annoying warning lights.  (WHAT specific warning lights, for FCOL).  Well, seems the lights were on, now, who’s at home?  

Aircraft grounded – Oh ho, you bet!   Engineering next.   Despite the paragraphs of window dressing, (all interesting stuff; duty times and the like, although ATSB do fail to mention what the engineer had for morning tea) - you get a sense of there being more to it, yet being told to move along, nothing to see.  Although, it may be just the tabloid style of reporting which gives that impression.  You know, drama, smoke, mirrors and sod all facts.

ATSB – “At about 2300 the engineer borrowed a nearby stand to provide a platform at about wing height.”

Stunning revelation.  If this is representative of the 'new' style ATSB report, the Murdoch press may be interested in using it.  It's not a bad 'press release', not too bad at all – but as an interim report on a very serious, potentially far reaching event?.....Well, at least we got a nice picture of the aircraft taxiing in....Stellar.

Please Senators, can we have our ATSB back.  Thank you.

[Gobbledock]

I shall now start calling it the "ATsB Albury Aberration"! That report is an absolute an utter crock of queerly written shit. Disgraceful.

What's next, an A380 bellyflops on to the Coathanger during rush hour and the final investigation report (15 years later) will say things like 'the aircraft was in the sky' or 'the aircraft had two pilots flying it' or 'the aircraft then crashed' or 'there was a large debris field'! No shit Sherlock!

Christ almighty, when did our industry get taken over MBA wordsmiths with penchants for writing soft reports containing nothing but queer speech?

I need to lay down, my head (and heart) hurts.

[Kharon]

Safety loop or hangman’s noose?

Ventus 45.

The final paragraph of:-
Investigation number: AO-2014-032 Updated: 10 June 2014
( https://www.atsb.gov.au/publications/inv...FI.twitter )

“The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser.”

For a “supposedly” benign and “routine” encounter with so called “moderate” turbulence, that should not have caused “any” damage or flight upset at all, the nature of this structural damage is alarming.

What we do know, is the aircraft was partially repaired and flown back to the manufacturer by the manufacturer’s test pilots, where it was “repaired” – presumably with the entire vertical tail and tail-plane removed and replaced – and was then subsequently flown back to Australia, to Virgin, and placed back in service.

Presumably, the “removed vertical tail and tail-plane” have been “examined” and or further “tested” by the manufacturer, and possibly (presumably) the “Design Certifying Authority”.
Presumably, the results of those investigations have identified the “reasons(s) for failure”, and have been dealt with in an “appropriate” manner, and the ATSB have been fully advised – of course. Frankly, I doubt it.

It is also interesting to note, that presumably, both the ATSB “AND” CASA were “quite happy” to grant a “permission to fly” for a “damaged” (partially repaired) aircraft over Australian Territory (and by inference – all other countries involved) for the “ferry flight” back to the manufacturer. Interesting point that, interesting indeed M’lud.

Why did they do so ? Why was the “physical evidence” (the tail and tail-plane) “allowed to leave the jurisdiction of the investigation”?

Why indeed ?

Two years on, and no definitive “structural report” ?

As the copper says at the crime scene: “Nothing to see here folks, move right along “thank you”, (and be bloody-quick-smart about it too).

I lifted the entire Ventus 45 post from Ben’s blog as it steps us through to what should have provided definitive answers to at least the ‘engineering’ parts of this puzzle.  It is remarkable that a manufacturer investigation of an event of this magnitude has not been fully documented.  It is not from idle curiosity or vicarious thrill seeking that answers are sought.  There are, clearly demonstrable areas of real concern which need to addressed: for example:-

Flight crew training and response to an uncertainty situation; there are many areas which have not been even cursorily examined.  The PIC ‘interference’ with the FO actions begs questions; why not call ‘taking over’; or, why not monitor and advise; or, why was there such confusion that the elevator channels were split. Etc.  There’s many more related to crew actions and reporting to engineering.

Then we examine what were the engineers told against what was committed to the tech log. This may give some insight into the initial maintenance actions.

The subsequent flights and tech logs preceding to eventual ‘discovery’ at Albury need to be examined in detail and crew questioned in relation to the in-flight performance of the aircraft.

No one is on a witch hunt here; not looking for a scapegoat in the form of an engineer or pilot.  However, this incident, like several others raises several red flags over ‘system’.  Hiding facts and delaying reports, then producing a ‘thing’ like the latest ATSB rubbish simply assists to hide potential problem areas, which, if not addressed could, when luck runs out end in an avoidable, preventable accident.

ATSB can do better than this – we know they can; so why are they not performing design function.  Perhaps when the minister gets done with taking selfies and studying phallic symbols, he could ask that question; maybe even do something about the shameful, deceitful way an expensive investigative body does it’s job.  He could even consider doing something to resurrect the inutile and transform it back to at least being honest, if not effective.  

Yes GD, I know there’s an election in the wind; so much more important than bodies and aircraft parts blowing in the same breeze.  Aye well; tempus fugit and tempers fray; I hope the inevitable never happens on some another day.

Toot toot.

[Peetwo]

ATSB O&O'd investigation No.??

Peetwo

[quote pid='393' dateline='1428906978']

[/url]Who is kidding who??

---

training wheels good catch and interesting article (& photo) from the [url=http://www.bordermail.com.au/story/2136758/bird-puts-plane-out-of-service/]Border Mail...

VH-FTS - How are CASA and the ATSB hiding things? I didn't realise they were the ones obligated to tell the press every time there was an accident or incident? Once the report is finalised, yes, but not during the initial investigation. I'd say they are probably doing their job properly behind the scenes - just because you, the pruner, doesn't know about it doesn't mean it's being handled poorly.

FTS I'm sure that you're probably right in regards to the investigators on the coalface doing their job properly, however I beg to differ with the rest of your statement.

Both of the occurrences in this case were listed as 'accidents' and both are being investigated. History shows that anytime a serious incident/accident is notified to the ATSB they will invariably post a media release within a day, if not hours, of the occurrence.

It is interesting that the BM article was released on the 08/03/14, some 11 days after the 2nd incident/accident, yet the article states:

The incidents are being treated as separate.

A Virgin Australia spokesman, Nathan Scholz, said there was no evidence linking the two matters.

Mr Scholz said that on February 20, the Sydney-bound flight struck turbulence that led to a crew member being injured and Virgin notified the bureau.

He said five days later the pilot reported a bird strike mid-flight and found damage to the outside of the aircraft upon landing to Albury.

However if we refer to the ATSB weekly summary lists for the 28 Feb 14 (entry 168) & 7 Mar 14(entry 182) we get the following notifications for the apparently unrelated occurrences (formatted differently but you'll get the picture):

20/02/2014 *201400786*Accident Yes - AO-2014-032* near Sydney Aerodrome* NSW* ATR - GIE Avions de Transport Regional ATR72-212A*
Air Transport High Capacity*Passenger* C * CTA

During cruise, the aircraft encountered severe turbulence resulting in a cabin crew member receiving a serious injury. The investigation is continuing.

25/02/2014*201400985*Accident Yes - AO-2014-032* near Albury Aerodrome* NSW * ATR - GIE Avions de Transport Regional ATR72-212A*
Air Transport High Capacity*Passenger* D * CTR

During a post flight inspection, substantial damage to the aircraft's tail assembly was detected. The investigation is continuing.

From this information we can establish that; (a) both events were listed as accidents and; (b) for some strange reason (& unbeknown to the BM reporter & VA spokesman) the bureau has given these (unrelated) events the same investigation number.

{Comment: It is also passing strange that the bureau makes no mention of the PIC's notified bird strike incident}

OK clear as mud so far?? Then we move further down the article to this bit right at the end...

"...The bureau spokesman in Canberra said a preliminary report would be prepared within 30 days..."

The 30 days passed on the 27th of March apparently without a prelim report being issued... However if you refer to investigation number AO-2014-032 you will see that it was last updated on the 25 March 2014. So technically speaking the bureau has come within it's promised deadline of 30 days. What is unclear is how the two occurrences were notified to the required parties (as per Annex 13 para 7.1) and whether there was a Preliminary report issued (to those parties) prior to the 30 days (as per para 7.4 of Annex 13).

Oh well I'm sure it is all above board.. However if that is the case when is the bureau going to make the Prelim report available to the rest of the world??

 
It should be noted that it is now 2 years 1 month & 27 days since the original incident (classified as an accident). And it is 1 year 10 months and 6 days since the investigation page has been updated - UFB! 

[/quote]

In an update to the ATSB O&O accident investigation - AO-2014-032 - here is some more commentary off the PT blog, note how the thread drifts to the point where Ben's original  message is totally lost:

20
Ventus45
Posted April 15, 2016 at 12:16 pm | Permalink
ggm said:-

“It feels like a recipe to actually MAKE bad things ensue, because you train the company to get away with not complying.”

Spot on mate.

Then Fred said:-

“at the risk of drawing the ire of some commentators..”

You have ………

“I should point out that according to Annex 13, interim reports are recommended in cases where the final report cannot be released within twelve months. They are not required.”
OK Fred, I will take you up on that.

THE PROBLEM is embedded in just that kind of “lawyer’s attitude”.

You do remember the little “game” our Chief Commissioner of the ATSB, Mr Martin Dolan, played on Senator David Fawcett in Senate Estimates during the PelAir – Norfolk Island Ditching hearings ?

It was all about which “edition” of Annex 13 applied, the “wording” – “shall” or “should”.
Fred, Annex 13 has been edited and amended so many times over the years, that it has been become a joke.

There is a thread on Aunty Pru about “investigative probity” (i.e. the “LACK OF IT”).
See here:-

http://auntypru.com/forum/-The-search-for-investigative-probity?pid=393#pid393

The sad fact is, that the “joke” will eventually be on people like you, those who fall for the “spin” and BS.

That ATR could have lost it’s tail in the next encounter with “moderate turbulence”.
It was only “grounded” after 5 days and 13 flights.

How lucky were the passengers and crews of those 13 flights ?

Do any of those people know they were in such potential peril ?

Should they ?

21
Fred
Posted April 15, 2016 at 12:55 pm | Permalink

Oh FFS get off your pedestal. I merely pointed out what Annex 13 says about interim reports. I also stated “I’m not excusing the ATSB for its lack of transparency…”.

22
Ventus45
Posted April 15, 2016 at 1:19 pm | Permalink
Fred, “not excusing” is not enough, it doesn’t cut the mustard.

Fred, a lot more people NEED to get up on the pedestal, and YELL – LOUD AND LONG – until parliament hears – AND ACTS.

If they don’t, what they will eventually hear, is a bloody lound “bank” and / or “boom” when an airliner crashes.

Then they will hear something else, that they will not be able to IGNORE.

23
Dan Dair
Posted April 15, 2016 at 4:29 pm | Permalink
Ventus45,

“a lot more people NEED to get up on the pedestal, and YELL – LOUD AND LONG – until parliament hears – AND ACTS”

If you truly believe that,
why are you wasting your time telling us, on this blog;
ie. the already converted,

instead of directly ‘yelling – loud and long’ at the politicians & regulators.?

After that Dan Dair drifts the thread for three more posts till Fred again posts:

Dan (#25),

Yes, I would certainly expect the ATSB to consider that aspect during its investigation. However, the ATSB can only make safety recommendations; it can’t enforce their implementation. That job belongs to the regulators.

&..then out of the blue WJR Hamilton posts   :

Folks,
At the risk of sounding like a lawyer (which I am not), under Australia’s complex, confusing and often contradictory air law, one thing remains clear. It is the person/entity who is the “registered operator” who, at all material times, remains responsible for the airworthiness of an aircraft.

Hiring of a maintenance contractor (the norm rather than the exception, these days) in no way lessens the responsibility of the “registered operator”. It doesn’t become a joint responsibility,(although a maintenance organisation may commit its own non-compliance with the law) it remains the responsibility of the registered operator.

As to the real reason for the initial incident, or the subsequent events, I have little confidence is seeing a satisfactory report.

However I would like to focus on these two quotes courtesy of Fred, first the one that captured the Ventus45 ire :

"..“The ATSB failed to produce a first or second anniversary interim report into these matters in accordance with ICAO protocols”.

I’m not excusing the ATSB for its lack of transparency in this matter. Nevertheless, at the risk of drawing the ire of some commentators, I should point out that according to Annex 13, interim reports are recommended in cases where the final report cannot be released within twelve months. They are not required..."

"..6.6 Recommendation.— [i]The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing theprogress of the investigation and any safety issues raised.."
[/i]
Okay I can (sort of) accept that, however as Ventus pointed out that after the very damning findings of the Senate AAI (PelAir) inquiry (where it was found the ATSB is a repeat offender of taking the Mickey Bliss of ICAO and Annex 13) I would of thought it prudent to at least appear to be compliant with the Annex.

It is also worth noting that for all traceable ATSB defined 'serious incident' investigations (active & historical) involving HCRPT aircraft, there has always been a interim report or statement issued on each anniversary of the occurrence. Given this occurrence was actually classified as an 'accident' then I would of thought it more prudent to be consistent with the accepted ICAO AAI Annex 13 principles.

Another point to note is that under A13 that a Preliminary report is required for.. 

"Accidents to aircraft over 2 250 kg

7.1 When the aircraft involved in an accident is of a maximum mass of over 2 250 kg, the State conducting the investigation shall send the Preliminary Report to..
...&
"..7.4 The Preliminary Report shall be sent by facsimile, e-mail, or airmail within thirty days of the date of the accident unless the Accident/Incident Data Report has been sent by that time. When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available..."


There does not appear to have been a prelim report issued either within 30 days or since for that matter. Oh but that's right for Annex 13 7.2 we have a notified difference:

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


Hmm...given the level of comments so far (above) I would of thought this was anything but a 'less complex' investigation?? 

While on the subject of the ATSB normalised deficiency of complying with ICAO Annex 13, if we refer to the more than 3000 Oz notified differences to ICAO under Annex 13 - https://www.airservicesaustralia.com/aip...5-h104.pdf - perhaps I can straigten out Fred's misconception that the ATSB routinely issue safety recommendations when a significant safety issue is identified in the course of an investigation:  

Fred - "the ATSB can only make safety recommendations; it can’t enforce their implementation. That job belongs to the regulators..."

From page 2 of the 10 pages (all 39 of them) of ATSB NDs of A13, safety recommendation defintion:

"..Essence of definition adopted in legislation and in policy and procedures documents. However, Australia reserves the term safety recommendation for making formal recommendations which are used as a last resort..."

This ND has in recent years (since 2008) has been stringently adhered to by the ATSB under Mr Dolan, to the point that the once obligatory SR for SSIs is almost redundant. The following is a link for a PAIN report that highlights the demise of the SR: http://auntypru.com/wp-content/uploads/2...opin_2.pdf

This was originally compiled for & during the PelAir inquiry so it is now somewhat post dated but the signs are that the SR decline trend has since stabilised.   

MTF..P2  

[Kharon]

Whispers, on the wind?

P2 - This was originally compiled for & during the Pel-Air inquiry so it is now somewhat post dated but the signs are that the SR decline trend has since stabilised.

It seems the release of  the polished, work-shopped version of the Pel-Air debacle even after some severe massaging has been delayed, yet again – expected mid year now.  This may have something to do with using election ‘white noise’ and distraction to float it out of sight and far away; but rumour suggests otherwise.  Seems the DIP have told ATSB to take the draft away and ‘get real’ i.e.. rejected; and, returned with some force.  This sort of thing always gets leaked and solemn promises not to mention what is contained in the draft, when respected always work.  I will say this; it’s no wonder the DIP have rejected the thing.

That’s it – MTF a racing certainty.

Toot toot.

[Peetwo]

Whispers, on the wind?

P2 - This was originally compiled for & during the Pel-Air inquiry so it is now somewhat post dated but the signs are that the SR decline trend has since stabilised.

It seems the release of  the polished, work-shopped version of the Pel-Air debacle even after some severe massaging has been delayed, yet again – expected mid year now.  This may have something to do with using election ‘white noise’ and distraction to float it out of sight and far away; but rumour suggests otherwise.  Seems the DIP have told ATSB to take the draft away and ‘get real’ i.e.. rejected; and, returned with some force.  This sort of thing always gets leaked and solemn promises not to mention what is contained in the draft, when respected always work.  I will say this; it’s no wonder the DIP have rejected the thing.

That’s it – MTF a racing certainty.

Toot toot.

More Beaker O&O bollocks??

"..Seems the DIP have told ATSB to take the draft away and ‘get real’ i.e.. rejected; and, returned with some force.."
 
Interesting rumour..    In an attempt to follow up - & knowing ATSBeaker don't always publicise updates to active investigations, especially those that are politically sensitive and they are providing top cover for - I dug out the re-investigation 'Update' page :   

Updated: 4 April 2016


The re-opened investigation has gathered a substantial volume of additional evidence, primarily from CASA and the aircraft operator, and has involved over 20 interviews with personnel from the operator and CASA, as well as information from the aircraft’s cockpit voice and flight data recorders. Analysis of the large volume of evidence obtained is continuing as is the development of the draft report, which is now expected to be released for review and comment by directly involved parties around the middle of the year. That analysis is focusing on:

• pre-flight planning and fuel management procedures and practices
  
• in-flight fuel management and related decision-making procedures and practices
  
• fatigue management procedures and practices
  
• flight crew check and training
  
• the operator’s oversight of its flight operations activities
  
• provision of weather and other flight information to flight crews
  
• cabin safety and survival factors
  
• regulatory oversight of activities such as those listed above
  

From that it can be seen that once again the ATSB has discretely (no fanfare) side-stepped notifying the general public and industry on the latest O&O of (re)-investigation AO-2009-072. Well no surprises there, hopefully this further delay update (& the circumstances for the latest delay) has been passed onto (as promised by Dolan) the Senators??

Although it could be that the DIPs (in this case CASA & the operator) have called for wholesale amendment to the DRAFT FR, the above would seem to put the first part of the rumour to bed. 

{P2 OBs - Reading between the lines it would appear that the lid has well & truly been lifted and now the rats are no doubt scurrying to find a bolt hole while the true, scurrilous, unadulterated version rears its ugly head}  

The other part of the rumour could well be true - i.e waiting it out till the cover of the election campaign & the transition to the new parliament. The timing would also (if a DD election) coincide with CC Dolan finally leaving the building, perfect opportunity to come clean. You know fresh start, new chapter, change of philosophy, cultural change and all that 'key word' spin & bulldust...

Personally I don't think so, all of the above will happen regardless of the PelAir re-investigation final report outcome. No I think this delay is more to do with the uncovering of much, much more disturbing revelations that even a dedicated Senate Committee were not able to uncover...

This was the last stated scoping by the ATSB in their 25 May 2015 update (in bold):

Updated: 25 May 2015


The previous update on 24 April 2015 outlined the results of a recent underwater survey of the aircraft’s wreckage. Based on this survey, the ATSB is currently assessing options for the task of recovering the recorders.

Other investigation activities to date have included:

• Reviewing documentation from the original ATSB investigation and the Senate Inquiry conducted by the Senate Rural and Regional Affairs and Transport References Committee in 2012-2013.
  
• Reviewing documentation from investigations into the accident conducted by the Civil Aviation Safety Authority (CASA) and the operator.
  
• Reviewing documentation from the operator, including flight records for several Westwind aircraft, check and training records for several flight crew, duty times and rosters, occurrence and hazard reports, audit reports, and safety committee meeting records.  
  
• Interviewing 14 personnel from the operator, including management, check and training pilots and line pilots.
  
• Comparing the operator’s policies and procedures and other requirements with its operational practices, particularly in areas such as flight planning, fuel management, fatigue management, and emergency procedures.
  
• Comparing the results from three bio-mathematical models of fatigue when applied to a series of the operator’s duty periods, and examining the suitability of the FAID model and related guidance material when applied to the operator’s air ambulance operations.
  
• Reviewing documentation from the air traffic services’ providers in Fiji and New Zealand about their policies and procedures for the provision of flight information, and how these were applied during the accident flight.
  
• Reviewing CASA’s surveillance files and related documentation for the operator.
  
• Reviewing documentation and interviewing personnel from the air ambulance contracting company.
  
  

During the Senate Inquiry associated with the original ATSB investigation, significant concerns were raised by some of the aircraft’s occupants about the serviceability and design of the life jackets used by three of the occupants. The re-opened investigation established that the life jackets had been retained by the Norfolk Island Police Force since the accident. The ATSB has now taken possession of the life jackets, and they will be examined after consultation with relevant parties. The life jackets were required to be serviced every 5 years, and all three jackets had been serviced within the 5-year period prior to the accident.

As well as continuing with the above activities, the next phase of the investigation will involve:

• Interviewing several personnel from CASA.
  
  
• Comparing the operator’s policies, procedures and practices with other air ambulance operators.
  
  
• Examining the reliability of weather forecasting at Norfolk Island.
  

 
& also on discovery that the CVR/FDR recordings were not corrupted and therefore useable, it was stated in the 19 October 2015 update:

The previous update on 25 May 2015 outlined the nature of the other investigation activities being undertaken by the re-opened investigation. These activities are close to being completed. In addition, the re-opened investigation has conducted interviews with both flight crew and both medical crew from the accident flight.

The investigation team are now in the process of analysing the available information and they have commenced the preparation of a draft report. Given the delay in recovering the recorders and the amount of information that has been collected and analysed, it is expected that a draft report will be released to directly involved parties for comment in early 2016.

If you think about it the potential ramifications of the latest (04 April) update, could lead to far more than yet another overdue & obfuscated ATSB (re)-investigation. I'm thinking on the implications for withholding evidence from a parliamentary inquiry...  


MTF...P2

[ventus45]

Interesting rumor - if true.

The "time-line" is "critical" here.

Being a sceptical ex-public-servant myself (left in June 2000) I suspect that the draft is just another "Whitewash Mk-2", which was deliberately drafted as such, in the "full knowledge and expectation", that one or more of the DIP(s) would "reject".

It is a time honoured administrative technique (which fits very well - when you "consider" the "resume" of the Chief Commissioner) for "delaying" or "pushing to the right" any "unpleasant business".

The usual reasons for doing so being either to :-
(a) "pass the bowl of poo" to your unfortunate departmental replacement, or
(b) "pass the bowl of poo" to the next minister, or indeed "government".

It all depends where the "driver for delay" is, in other words, where the "potential - probable - inevitable" HURT will be felt "when the music stops".

So, if the "driver" is "political", it will be (b). If the "driver" is "departmental" (ATSB and/or CASA) it will be (a).

So, I wonder, - which (one or more) of the various "DIP(s)" have "rejected", and "why" ?

The "who(s)", might be more telling of the "hidden reasons", than the most probabe and "obvious" public why(s).

In any case, the delay will now clearly push the "time-line to the right", in accordance with the plan, i.e. beyond:-
(a-i) the current Parliament (essential)
(a-ii) the current SENATORS (crucial objective for the Chief Commissioner)
(a-iii) the current Minister
(b) the Election,
(c-i) the end of the MH-370 sarch, ("most crucial" objective for the Chief Commissioner, for he can then "retire"),
(c-ii) the departure (retirement, rather than dismissal) of the present Chief Commissioner.

So, in short, nothing new or unexpected.

Indeed, as I posted months ago, with minor variations (perhaps), things are going "quite as expected" at this keyboard.

[Gobbledock]

Ventus post = 10/10. Nailed it in one mate  

[Kharon]

P2 – “If you think about it the potential ramifications of the latest (04 April) update, could lead to far more than yet another overdue & obfuscated ATSB (re)-investigation. I'm thinking on the implications for withholding evidence from a parliamentary inquiry..”

I reckon V45 has nailed it – for the normal, run of the mill, routine delay and obfuscation we expect for every ‘incident’.  PC and ‘sensitivity’ levels are always high and of course the CASA legend must not be tarnished, nor the predetermined outcome be challenged.  This is the ATSB raison d'être under the Beyond all Reason system.

Even so – P2 (IMO) creeps close to the deeper reasons; but not for ‘withholding’.  Turn it around. We know the Senators hold some pretty damning information and have a pretty fair idea of the real why’s and wherefores.  Beaker ain’t got a lot of latitude and no matter how ‘narrow’ a focus the report takes, the Senate ‘evidence’ must be acknowledged, dealt with and be visible in the report; or else, take it away and do it again - properly. Repeat as often as needed.  

P2 – “No I think this delay is more to do with the uncovering of much, much more disturbing revelations that even a dedicated Senate Committee were not able to uncover..”

IMO a slight correction is needed there: [much] more disturbing revelations that even a dedicated Senate Committee were able to uncover  - but lacked enough empirical evidence to make it stick.  This is being used to keep Beaker and Co. honest, force probity into the set piece. If you take the V45 argument + P2 logic there are many reasons to delay the report until the golden parachutes are fully deployed and the fur lined jock straps have been hand crafted to ensure maximum protection and comfort.  

Aye, you can run, but you can’t hide.  (Joe Louis).

Toot toot.

[Peetwo]

..Being a sceptical ex-public-servant myself (left in June 2000) I suspect that the draft is just another "Whitewash Mk-2", which was deliberately drafted as such, in the "full knowledge and expectation", that one or more of the DIP(s) would "reject"...

..So, I wonder, - which (one or more) of the various "DIP(s)" have "rejected", and "why" ?

The "who(s)", might be more telling of the "hidden reasons", than the most probabe and "obvious" public why(s)...

..I reckon V45 has nailed it – for the normal, run of the mill, routine delay and obfuscation we expect for every ‘incident’.  PC and ‘sensitivity’ levels are always high and of course the CASA legend must not be tarnished, nor the predetermined outcome be challenged.  This is the ATSB raison d'être under the Beyond all Reason system.

Even so – P2 (IMO) creeps close to the deeper reasons; but not for ‘withholding’.  Turn it around. We know the Senators hold some pretty damning information and have a pretty fair idea of the real why’s and wherefores.  Beaker ain’t got a lot of latitude and no matter how ‘narrow’ a focus the report takes, the Senate ‘evidence’ must be acknowledged, dealt with and be visible in the report; or else, take it away and do it again - properly. Repeat as often as needed... 

...IMO a slight correction is needed there: [much] more disturbing revelations that even a dedicated Senate Committee were able to uncover  - but lacked enough empirical evidence to make it stick.  This is being used to keep Beaker and Co. honest, force probity into the set piece. If you take the V45 argument + P2 logic there are many reasons to delay the report until the golden parachutes are fully deployed and the fur lined jock straps have been hand crafted to ensure maximum protection and comfort...

From a horse's mouth -

Ok I can accept the "V" & "K" speculative hypotheticals on what the last (April 04) ATSB update to the PelAir cover-up re-investigation actually means. Given the historical evidence that we already have in the lead up to the last election, this is the most obvious synopsis to make:

Ventus - In any case, the delay will now clearly push the "time-line to the right", in accordance with the plan, i.e. beyond:-

(a-i) the current Parliament (essential)

(a-ii) the current SENATORS (crucial objective for the Chief Commissioner)

(a-iii) the current Minister

(b) the Election,

(c-i) the end of the MH-370 sarch, ("most crucial" objective for the Chief Commissioner, for he can then "retire"),

(c-ii) the departure (retirement, rather than dismissal) of the present Chief Commissioner.

 
However I have it from a reliable source (in other words a DIP) that there has not been any sign of a DRAFT report passed on for DIP review, as per the TSI Act:

26 Draft reports


(1) The ATSB may provide a draft report, on a confidential basis, to

any person whom the ATSB considers appropriate, for the purpose

of:

(a) allowing the person to make submissions to the ATSB about

the draft report; or


(b) giving the person advance notice of the likely form of the

published report.

    
In fact there has been no update or even contact since the DIPs were re-interviewed some two months ago. Not sure what that all means in the grand scheme of things but it does confirm the veracity of this statement in their latest update...

"..The re-opened investigation has gathered a substantial volume of additional evidence, primarily from CASA and the aircraft operator, and has involved over 20 interviews with personnel from the operator and CASA, as well as information from the aircraft’s cockpit voice and flight data recorders. Analysis of the large volume of evidence obtained is continuing as is the development of the draft report, which is now expected to be released for review and comment by directly involved parties around the middle of the year..." 

Who knows whether or not this 'statement of intent' is designed to coincide with the election & consequently Ventus (a) & (b) assumptions ..

 "..The usual reasons for doing so being either to :-

(a) "pass the bowl of poo" to your unfortunate departmental replacement, or

(b) "pass the bowl of poo" to the next minister, or indeed "government".."

However what I will say is that from past statements from Dolan & Co in Estimates, I get the feeling that they wanted this embarrassing re-investigation well and truly done & dusted by now.

19/10/15 Supplementary Estimates:

Senator FAWCETT: Mr Dolan, I saw on your website today that you have issued an update to the reopening of the investigation into the Pel-Air accident.


Mr Dolan : Yes.


Senator FAWCETT: Could you give the committee, in this forum, a brief on the status of that reopened investigation.


Mr Dolan : At this stage the update related to the contract that I said I signed last week.

The information-gathering stage of the reopened investigation is essentially complete, and so the work is now going through to assess all the additional information that has been acquired to draw conclusions so that a draft report can be prepared before Christmas.  

28/05/15 Budget Estimates:

Senator XENOPHON: I think ATSB has stated that it would like to complete the reopened Pel-Air investigation before Christmas. Is that still a likely time frame?

Mr Dolan : Yes. If there are significant delays in the recovery of the recorders, that might put a delay into it, but our aim still is to complete it before Christmas.

MTF...P2

[ventus45]

Which Christmas ..........?
Christmas in July .............?
Um,........ which year / decade / ...........?

[Kharon]

Would you buy a used car from the ATSB?

V 45... - Which Christmas indeed.  Did a bit of digging about the place; seems P2 has it right; no contact with DIP.  Mind you, this is normal; ASTB does this interview then silence thing; I’ve often wondered why.  When the ‘fuzz’ (bless ‘em) do an investigation I notice they may come back to ‘witness’ a couple of times to confirm or clarify a point of interest or salient detail.  Of course the police need to be certain and are cautious when dealing with ‘fact’ and ‘evidence’ which will be tested in court; so they need to get it right (ish).  There are no such constraints on ATSB, they are free to ignore ‘evidence’, disregard statements, massage fact and generally ‘cherry-pick’ the bits of an incident that best suit; without the tale ever being challenged by counsel in court.  

I could stand to be corrected here. – But I believe in NSW, the police (air wing?) provide the final report to the coroner, but only when there has been a fatal.  I would like to see that system expanded to where the ATSB must follow the same procedure for all serious ‘incidents’. Be subject to the rules of evidence, as the police are obliged to be; as in full expectation of having ‘their’ case challenged.  This system should apply to all ‘serious’ incidents.  Take Pel-Air as an example; what a mess.  Can you imagine the response from senior plod if a police investigation had been conducted in the same manner?  I can, and it would not be pretty.  Take it to the next step and imagine a police investigation winding up as a Senate inquiry and being subject to the same level of criticism from parliament.  The roof would be off the building at very least, with the minister responsible following.  

I guess the point I’m struggling to make is that any form of investigation needs to be able to withstand scrutiny and challenge; evidence and statements all matter and such facts as are relied on must unimpeachable; or at least ‘solid’ enough to withstand ‘testing’.  I have not read one ATSB report in the last six years which has withstood the test of our senior panel; at best there are ‘technical’ gaffs, at worst; – well, you have all followed the Pel-Air saga. We pay a huge amount for the best efforts of the ATSB; we depend on the ATSB reports to formulate strategy and develop systems to avoid a repeat of accident or incident.  We do not get this service from ATSB.  Something is very, very wrong within the organisation.  It never used to be so; ATSB were at one time a world famous exemplar, respected and valued; not so these days.  Hells bells, even the drive to save pennies is farcical, considering the final cost of the Pel-Air report. Have you ever stopped to consider, just in fiscal terms the cost of this aberration.  Senate inquiry costs, Forsyth review costs, Canadian peer review costs, reinvestigation costs, etc.   All because ATSB and CASA, unlike the coppers, cannot be held responsible or accountable for the way they behave; or, execute their remit; or, even do their job.    

Please can we have our real ATSB back; the current iteration is a disgrace and an embarrassment.

Toot toot.

[ventus45]

Good morning K.

A well well written summary of the state of play "K".

As I see it, two lines identify the core issue.

(A)  I guess the point I’m struggling to make is that any form of investigation needs to be able to withstand scrutiny

and challenge; evidence and statements all matter and such facts as are relied on must unimpeachable; or at least

‘solid’ enough to withstand ‘testing’.

(B)  All because ATSB and CASA, unlike the coppers, cannot be held responsible or accountable for the way they behave;

or, execute their remit; or, even do their job.    

If I may take the liberty of stripping them down to their component parts...............

(A)  ........(i)   any form of investigation needs to be able to withstand scrutiny and challenge;
            (ii)  evidence and statements all matter and:-
            (iii) such facts as are relied on must unimpeachable; or
            (iv)  at least ‘solid’ enough to withstand ‘testing’.

AND

(B)  ........All because ATSB and CASA, unlike the coppers,
            (i)   cannot be held responsible or accountable;
            (ii)  for the way they;
                  (--i)  behave; or,
                  (-ii)  execute their remit; or, even
                  (iii)  do their job.    

Question:        
 
"Why" is it so ?  (Professor Julius Sumner Miller)

Short Answer:      

(i)     The "Law(s)" themselves.  (Where "laws" is a "catch-all" for UN - ICAO - Acts of Parrliament - et. al.)
(ii)    They have been "allowed" to become "laws unto themselves", by the parliament itself.

As I see it, the core of the problem, goes rite back to the so-call "Chicago Convention" itself.

It is perhaps ironic, that the frustration that we, and the current dear Senators, have endured, and will continue to endure, is a function of the overall regulatory regime in being, which can only be sheeted home to their parliamentary predecessors, who, through their lack of foresight, ratified a convention that established the "god" ICAO (complete with Annex-13 - as amended (many times) - as Beaker so gleefully pointed out) and who have subsequently allowed (and even fostered) the creation of the mess of the dysfunctional and unaccountable ATSB that we have today, by enacting the TSI Act, which effectively makes the ATSB a "law unto itself", AND BEAKER LOVES IT !  

In a perverse sort of way, it makes him even more powerful and "untouchable" than his boss, Murky !  
He must love that !!

To understand what has happened - and "why" we are where we are today, it is necessary to go rite back to "square-one".
Start here:  http://www.icao.int/publications/pages/doc7300.aspx

It is all about "money". There is an old saying in the criminal investigation world = "follow the money trail" - in the aviation case, to the Montreal Convention.

Byron Bailey is "on the trail".  http://auntypru.com/forum/-Less-Noise-an...56#pid4056

In case anyone is wondering, this is the actual Montreal Convention Document itself.
https://infrastructure.gov.au/aviation/i...ention.pdf

Did you notice the "irony" in the "host page" in the URL ?  I leave it to you.
The host page is https://infrastructure.gov.au/aviation/i...ility.aspx
Some "interesting" reading there, background "mind-set" in-sights for further consideration.

Moving right along now.

This is from ICAO.
http://www.icao.int/secretariat/legal/Li...l99_EN.pdf

These are from IATA.  

http://www.iata.org/policy/Documents/Pos...r_mc99.pdf

https://www.iata.org/policy/Documents/MC99_en.pdf

It is now no longer morning.  
I did have plans for today "K", but you buggered 3 hours for me !
Rescheduling tasks - "bugga" !

[Kharon]

Good morning V; I do, most sincerely apologise Sirrah for buggering up your schedule –

However; your analysis takes the discussion to a more basic, less esoteric level; to that of trust.  For many years I, like the rest of the aviation community have taken the ATSB investigations at face value; and, why not? Things like the ‘crash comic’ and reports into accidents were impeccable reference and advice sources, trusted and appreciated by all.  It has taken the last few years for ATSB to destroy that faith, it was not easily done.  Indeed I resisted the nagging doubts and the small shouts of bollocks which crept in while reading for a long while.  It was not until I had ‘in-depth’ personal knowledge of what really happened in a few fatal accidents that the rot really set in; which prompted seriously deep analysis and investigation.  The method used was holistic – working backwards from response to SR and Coroner recommendations to deep accident background.  Then validating, revaluating recommendations, response to recommendations and subsequent actions taken to positively prevent a repeat event.  To do this we needed to drag CASA into the matrix.  I won’t bore you with the results; suffice to say the conclusions left much to be desired and begged the questions; WTF and why?

That aside we hit the wall of trust.  We should, without hesitation or doubt be able to look at any accident report and subsequent response and believe it.  This has not been possible for the last few McComic driven Beyond all Reason years.  

Unless we see a radical change in ATSB and real reform of the regulator, there is little to gained by pouring obscene amounts of public money down this sewer. As it stands, we may as well save the dollars and be better off relying on the UP for ‘analysis’. We are (IMO) at a sorry impasse where every element of an accident or incident report must be challenged and ‘tested’ for probity, accuracy and effectiveness of purpose.  Look at the ridiculous, recently released VMC into IMC report for an example of inutile reporting.  Take a deep look at Pel-Air or, better still Canley Vale; then ask the question, can I trust these unaccountable people?   The short answer in No; the long answer is No Ducking Way.  Now, if it was your friend or relative being shovelled into a body bag, what sort of answers would you like to see provided? Certainly not the platitudes and fluffy yarns ATSB eventually crank out.

If we cannot rely on their reports, then the reports need to be tested, every element proven beyond reasonable doubt, the conclusions examined; and, like the Pel-Air report, stripped down until some semblance of fact may be relied on.  This so the expensive report may be of some actual value (practical or intrinsic) to those who paid for it and must rely on it.  Then we need to see what the regulator does in response; but that is another tale, for another page, on another day.

Toot toot… .