[Peetwo]

Is it just me?

Yesterday the ATSB released their final 'Short Investigation Bulletin' for the year - Aviation Short Investigations Bulletin - Issue 45. At the top of the SIBs page it states:

 "..Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research..."

This is Dolan speak (weasel words), for.. "we have limited resources to spend on full blown incident (versus accident) investigations, so if a desktop investigation can be conducted  which will conserve resources then that is what we will do."

However I am not sure if pushing that 'Short Investigation' definition to include a 'serious incident' where a near collision involving a 60 tonne Orion P3-C aircraft and a Schweizer 269C helicopter, over a built up area necessarily justifies a limited, short investigation budget - AO-2015-101.

On sighting the Orion, the pilot of JXO had immediately initiated a climb to avoid a collision, and estimated the Orion passed about 100 ft below. On hearing the controller pass the Orion as traffic to the pilot of JXO, the Orion crew immediately became concerned about the helicopter’s proximity, and looked for it. The co-pilot (non-flying pilot) of the Orion sighted JXO, assessed there was a risk of collision, and called ‘go low, go low, go low’. The captain (flying pilot), also sighted JXO, and increased the rate of descent to pass beneath the helicopter. The Orion crew estimated that JXO passed about 50 ft directly above the Orion, and were concerned it may collide with the Orion’s vertical tail fin. On the radar SDD, at 1514:25, both aircraft appear in the same position at 600 ft (Figure 6).

It is evident, from the safety actions section of the report, that the RAAF are taking this incident very seriously:

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Department of Defence
As a result of this occurrence, the Department of Defence advised the ATSB that they are taking a number of safety actions. These include the following:

Compromised separation recovery training

The Department of Defence has released a Standing Instruction that mandates annual compromised separation recovery training for all air traffic controllers.

Controller briefing

All controllers will be briefed on the events and findings of the incident as an element of compromised separation recovery training.

Tower simulation capability

Tower simulation capability is being introduced to enhance compromised separation recovery training.

Additionally, simulation will be used to:

• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with processing complex traffic scenarios
  
• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with application of ATC priorities
  
• assess controller proficiency when live traffic levels are below that required to judge controllers’ abilities to process complex traffic scenarios
  
• provide controllers with regular exposure to compromised separation recovery scenarios, to improve decision making and ensure the associated actions become instinctive.
  
  

Airspace procedure briefings

The Edinburgh controllers will provide airspace procedure briefings to pilots who conduct airwork within and around Edinburgh airspace. The Airservices Australia Aeronautical Information Publication (AIP) En Route Supplement Australia (ERSA) entry for Edinburgh will be amended to include a section detailing the requirements for pilots of civil aircraft intending to conduct airwork within, or near, the Edinburgh control zone, to have airspace briefing.

 Hence (I guess) the ATSB quick wrap up of this investigation. However this incident had the potential for a lot more civilian fatalities than the sole occupant of the helo, if the Orion aircraft, minus tailfin, was unable to recover and spun out of control into outer Adelaide suburbia. 

Figure 2: Operating area of JXO, Edinburgh Control Zone and relative tracks


Source: Airservices Australia – annotated by the ATSB  

Maybe it is just me but a visual separation estimate of between 50-100 feet is just way too close for comfort - UFB!

P2 Comment: That said the ATSB Short Investigation team member(s) in collating and writing that report (in less than 4 months), did a sterling job with, 'by definition', very limited resources - Top job!

Update from AAP via the Oz:

Helicopter, plane in 15m near-miss over Adelaide

• AAP
  
• December 23, 2015 10:41AM
  

An RAAF Orion class plane came so close to a helicopter that its crew feared the tail section would hit the chopper.

A military aircraft and a commercial helicopter came within 15 metres of each other over Adelaide in August, with the near miss blamed on communication issues.

A report into the incident says an Air Force Orion passed just below the helicopter after the chopper was given clearance to track towards the RAAF Edinburgh Base tower when a controller mistook the pilot’s request.

Crew on-board the Orion later told investigators they feared the plane’s vertical tailfin would hit the helicopter.

The incident happened on August 31 as the Orion was coming in to land at Edinburgh Airport just after 3pm, following a 10-hour international flight.

About the same time, the pilot of a Schweizer 269C helicopter asked Edinburgh air traffic control for the green light to head towards Clare.

Confusion started when the air traffic controller mistook the pilot’s request to ‘Clare’ for nearby ‘Calvin Grove’ airfield near Virginia, from where the helicopter had taken off.
Instead, the pilot was told to track direct to the control tower to separate it from the Orion and another aircraft completing circuits.

On a number of occasions, the helicopter pilot tried to contact their employer about flying in the direction of the tower using UHF radio.

A circuit aircraft was cleared to land and take off again and told air traffic control the Orion was in sight.

According to the report, the controller examined the tracking of all three aircraft and assessed the helicopter would safely cross in front of the Orion and behind the circuit plane.

The error then went uncorrected because the pilot of the helicopter had selected the wrong radio band.

“The pilot was flustered and expecting an onwards clearance to Clare Valley, (and) consequently had turned right to track northwards to Clare Valley,” the report stated.

According to the report, the two aircraft appeared in the same position on the radar at an altitude of 180m at 3.14pm.

The helicopter pilot reported feeling “a bit rattled” when interviewed by ATSB investigators.

“The pilot was nervous about operating in military controlled airspace and therefore did not question the clearance to track towards the tower,” the report said.

“The pilot had selected Clare Valley on the GPS and was unsure exactly where Calvin Grove was from their current position.”

The Australian Transport Safety Bureau says the incident demonstrates the potential consequences of a loss of communication.
AAP

MTF..P2

[Peetwo]

Is it just me?

Yesterday the ATSB released their final 'Short Investigation Bulletin' for the year - Aviation Short Investigations Bulletin - Issue 45. At the top of the SIBs page it states:

 "..Released periodically, the Bulletin provides a summary of the less-complex factual investigation reports conducted by the ATSB. The results, based on information supplied by organisations or individuals involved in the occurrence, detail the facts behind the event, as well as any safety actions undertaken. The Bulletin also highlights important Safety Messages for the broader aviation community, drawing on earlier ATSB investigations and research..."

This is Dolan speak (weasel words), for.. "we have limited resources to spend on full blown incident (versus accident) investigations, so if a desktop investigation can be conducted  which will conserve resources then that is what we will do."

However I am not sure if pushing that 'Short Investigation' definition to include a 'serious incident' where a near collision involving a 60 tonne Orion P3-C aircraft and a Schweizer 269C helicopter, over a built up area necessarily justifies a limited, short investigation budget - AO-2015-101.

On sighting the Orion, the pilot of JXO had immediately initiated a climb to avoid a collision, and estimated the Orion passed about 100 ft below. On hearing the controller pass the Orion as traffic to the pilot of JXO, the Orion crew immediately became concerned about the helicopter’s proximity, and looked for it. The co-pilot (non-flying pilot) of the Orion sighted JXO, assessed there was a risk of collision, and called ‘go low, go low, go low’. The captain (flying pilot), also sighted JXO, and increased the rate of descent to pass beneath the helicopter. The Orion crew estimated that JXO passed about 50 ft directly above the Orion, and were concerned it may collide with the Orion’s vertical tail fin. On the radar SDD, at 1514:25, both aircraft appear in the same position at 600 ft (Figure 6).

It is evident, from the safety actions section of the report, that the RAAF are taking this incident very seriously:

Safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Department of Defence
As a result of this occurrence, the Department of Defence advised the ATSB that they are taking a number of safety actions. These include the following:

Compromised separation recovery training

The Department of Defence has released a Standing Instruction that mandates annual compromised separation recovery training for all air traffic controllers.

Controller briefing

All controllers will be briefed on the events and findings of the incident as an element of compromised separation recovery training.

Tower simulation capability

Tower simulation capability is being introduced to enhance compromised separation recovery training.

Additionally, simulation will be used to:

• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with processing complex traffic scenarios
  
• compensate for low traffic levels and to facilitate controller attainment and retention of skills associated with application of ATC priorities
  
• assess controller proficiency when live traffic levels are below that required to judge controllers’ abilities to process complex traffic scenarios
  
• provide controllers with regular exposure to compromised separation recovery scenarios, to improve decision making and ensure the associated actions become instinctive.
  
  

Airspace procedure briefings

The Edinburgh controllers will provide airspace procedure briefings to pilots who conduct airwork within and around Edinburgh airspace. The Airservices Australia Aeronautical Information Publication (AIP) En Route Supplement Australia (ERSA) entry for Edinburgh will be amended to include a section detailing the requirements for pilots of civil aircraft intending to conduct airwork within, or near, the Edinburgh control zone, to have airspace briefing.

 Hence (I guess) the ATSB quick wrap up of this investigation. However this incident had the potential for a lot more civilian fatalities than the sole occupant of the helo, if the Orion aircraft, minus tailfin, was unable to recover and spun out of control into outer Adelaide suburbia. 

Figure 2: Operating area of JXO, Edinburgh Control Zone and relative tracks


Source: Airservices Australia – annotated by the ATSB  

Maybe it is just me but a visual separation estimate of between 50-100 feet is just way too close for comfort - UFB!

P2 Comment: That said the ATSB Short Investigation team member(s) in collating and writing that report (in less than 4 months), did a sterling job with, 'by definition', very limited resources - Top job!

Update from AAP via the Oz:

Helicopter, plane in 15m near-miss over Adelaide

• AAP
  
• December 23, 2015 10:41AM
  

An RAAF Orion class plane came so close to a helicopter that its crew feared the tail section would hit the chopper.

A military aircraft and a commercial helicopter came within 15 metres of each other over Adelaide in August, with the near miss blamed on communication issues.

A report into the incident says an Air Force Orion passed just below the helicopter after the chopper was given clearance to track towards the RAAF Edinburgh Base tower when a controller mistook the pilot’s request.

Crew on-board the Orion later told investigators they feared the plane’s vertical tailfin would hit the helicopter.

The incident happened on August 31 as the Orion was coming in to land at Edinburgh Airport just after 3pm, following a 10-hour international flight.

About the same time, the pilot of a Schweizer 269C helicopter asked Edinburgh air traffic control for the green light to head towards Clare.

Confusion started when the air traffic controller mistook the pilot’s request to ‘Clare’ for nearby ‘Calvin Grove’ airfield near Virginia, from where the helicopter had taken off.
Instead, the pilot was told to track direct to the control tower to separate it from the Orion and another aircraft completing circuits.

On a number of occasions, the helicopter pilot tried to contact their employer about flying in the direction of the tower using UHF radio.

A circuit aircraft was cleared to land and take off again and told air traffic control the Orion was in sight.

According to the report, the controller examined the tracking of all three aircraft and assessed the helicopter would safely cross in front of the Orion and behind the circuit plane.

The error then went uncorrected because the pilot of the helicopter had selected the wrong radio band.

“The pilot was flustered and expecting an onwards clearance to Clare Valley, (and) consequently had turned right to track northwards to Clare Valley,” the report stated.

According to the report, the two aircraft appeared in the same position on the radar at an altitude of 180m at 3.14pm.

The helicopter pilot reported feeling “a bit rattled” when interviewed by ATSB investigators.

“The pilot was nervous about operating in military controlled airspace and therefore did not question the clearance to track towards the tower,” the report said.

“The pilot had selected Clare Valley on the GPS and was unsure exactly where Calvin Grove was from their current position.”

The Australian Transport Safety Bureau says the incident demonstrates the potential consequences of a loss of communication.
AAP

&..from the ABC online:

Military plane and civilian helicopter narrowly avoid collision over Adelaide's northern suburbs

Updated Wed at 9:54am Wed 23 Dec 2015, 9:54am

Photo: The two aircraft came within 15 metres of each other on August 31. (RAAF)

Map: Edinburgh 5111

An Air Force Orion and a civilian helicopter nearly collided near Edinburgh Airport in Adelaide's northern suburbs in August, a report by the Australian Transport Safety Bureau (ATSB) has confirmed.

An investigation into the near miss by the ATSB said the crew of the Orion thought the helicopter would hit its vertical tail fin, as the two aircraft came within 15 metres of each other on August 31.

The bureau said the near miss was caused by communication delays between an air traffic controller at the Edinburgh Air Force base and the helicopter pilot, who did not see the Orion at first.

The helicopter had been cleared to fly over the area while the Lockheed AP-3C Orion with five crew and 14 passengers was approaching Edinburgh and had priority to land.

The crew of the Orion increased its rate of descent to avoid a collision, while the helicopter pilot made a rapid climb.

The Defence Department has told the ATSB it is boosting safety training in response to the incident.

The Schweizer 269 helicopter had been aerial spraying in the Edinburgh area at the time of the incident

MTF..P2

[Peetwo]

DSB v ATSB POC - A cluster of Duck-ups

#Post255

Helicopter strays into jets’ airspace in Melbourne

#Post262-265 (previous page)

Passenger video gives inside view of ATC screw up at Melbourne Airport

NX Quotes:

[b]“Airservices Australia agreed this was a serious incident, but it took more probing and letters from me before night time LAHSO operations were suspended at Melbourne Airport from 10th November 2015 — over four months after the incident,” he said.

“When it comes to safety there must be no scrimping of staff, and we should be adopting world’s best practice,” he said.
[/b]
Senator Xenophon said the double go-around was described in risk assessment modelling as a one-in-175-year event, but that two such events had occurred in the last five years.

“It seems there is something seriously wrong with this so-called risk assessment modelling when it comes to aircraft hurtling along at 800km per hour,” Senator Xenophon said.

Be forewarned & be prepared -
Hoodlum appears to have embraced the NX & RRAT Committee forewarnings prior to last Estimates, from ASA Hansard:

Senator XENOPHON: It is good to hear that. Can I just go to the issue of the question I put on notice about the incident that took place in Melbourne, in Essendon Airport, on 12 November 2013, which you are familiar with?


Mr Harfield : Correct.

Senator XENOPHON: You indicated in an answer that Airservices had reviewed coordination procedures and in July 2014 implemented a number of actions, which I will not have to repeat—although my understanding is that those questions were due in December and we did not get them until February. Is that right?

Mr Harfield : We provided the questions on notice in return in accordance with the time lines.

Senator XENOPHON: So, if we did not get them, that might have something to do with the department.

Mr Mrdak : I explained earlier there was some delay in having some of the questions completed but then also cleared by the minister.

Senator XENOPHON: So the minister did not clear them within the time required by the Senate. So you guys complied within the time frame. If it said by 4 December, for instance, you would have provided it to the department, to the minister's office, by 4 December, or whatever the time line was? I am satisfied with that. That is relevant in the following context. You answered that you implemented a number of actions about Melbourne Tower, keeping them informed in terms of the status of Essendon. Melbourne Tower was advised of aircraft conducting instrument approaches to runway 26 at Essendon. Melbourne Tower's was given increased awareness of potential conflicts which are operating on runway 16 for departures. In addition, an interim system enhancement has been implemented which involves a visual prompt. So all these safeguards were put in place. What I am trying to understand is—and I wrote to your chair, Sir Angus Houston, recently—you are aware of what happened at Melbourne and Essendon airports on Australia Day this year?

Mr Harfield : That is correct.

Senator XENOPHON: Can you just run us through that very briefly, because it concerns me that it has happened again, despite these processes that have been put in place.

Mr Harfield : It may be easier to run through a document I can table which actually has both the incident of 12 November 2013—the original incident—

CHAIR: Do you want to table that?

Mr Harfield : Yes. I have got that one to be tabled. It has got the actions taken but also the event of 26 January and the details associated with that.

Senator XENOPHON: Maybe we could get some copies through the secretariat.

Mr Harfield : I have got some copies here as well.

Senator XENOPHON: I move that it be tabled.

CHAIR: Yes; we—

Senator XENOPHON: I am trying to get through it, Chair. So you understand my concern in this regard? I obviously have not had an opportunity to look at this. You understand my concern that—

Mr Harfield : I very much understand your concern that there are two incidents that are very similar. As you will see from the document that we have provided and tabled, there are some extra circumstances that occurred differently from the first one that created the same event, and that is what we are investigating, to put in extra mitigation to ensure that it does not happen again.

Senator XENOPHON: It is a pity I did not see this beforehand, because I obviously will not be able to ask you questions about it. I may have to put some questions on notice or ask them at the following estimates or another committee hearing...

  
Okay so there were 2 ASA tabled documents & they are now publicly available:

2.) Document titled 'Information Brief: Melbourne Basin Coordination Incidents'. Tabled by Airservices Australia on 8 February 2016.


(PDF 1653KB)

3.) Document titled 'Information Brief: LAHSO at Melbourne Airport'. Tabled by Airservices Australia on 9 February 2016.

(PDF 4836KB) 

  
No 2) above was the one that Harfwit refers in Hansard:


The second briefing -  on the LAHSO & related double go round incident - by Hoody was equally as good & provides another concise timeline that doesn't paint CASA in a particularly - shall we say - proactive light...  

It is encouraging to see that Hoody is getting on with the job of proactively tackling some of these recently identified significant safety issues to do with ATC in YMML...

However the cluster of serious incidents recorded for in & around YMML (Tullamarine International Airport) and the associated airspace should be of particular concern for the ATSB.  Yet I don't believe (I could stand to be corrected ) that the supposedly independent air safety investigator, has initiated any research investigations into the rising list of serious occurrences in and around Melbourne airport - Why not?

In a fascinating comparison it just so happens that the Dutch Safety Board has just initiated an investigation into Amsterdam Airport Schiphol:

Investigation

• 
  Nieuws2 Mar 2016
  
  Investigation into air traffic safety at Amsterdam Airport Schiphol
  The Dutch Safety Board has started a thematic investigation into air traffic safety at and around Amsterdam Airport Schiphol. Over the past few years, the Dutch Safety Board has investigated multiple incidents at the airport. With a view to further improving safety at Amsterdam Airport Schiphol, the Board now wishes to investigate whether these incidents may be due to multiple root problems, such as the design, location and use of the airport. Not only is this important for the current handling of air traffic, but also given the generally expected growth in the numbers of flights at Schiphol in the decades ahead.
  
  Among other things, the investigation will determine whether the parties involved followed up the Board's previous recommendations. The Board also wishes to gather information on how the parties involved have been fulfilling their responsibilities with respect to the various safety aspects of air traffic. Indeed, the Board wants to examine how the safety of local residents features in decisions on Schiphol and how the interests of safety, economy and the environment are balanced.
   
  The events and incidents investigated previously by the Board included aircraft taking off from a runway not cleared for use, runway incursions (i.e. vehicles crossing or driving on a runway in use for air traffic) and technical problems.
  

        
From that brief investigation summary it doesn't appear (unlike our ATSB) to be beholden or PC'd in regards to any DIPs (Airport owners, ATC or regulator) and they certainly aren't going to shirk their responsibilities as the ICAO State approved AAI..
MTF...P2

[Peetwo]

Another ATSB report for PAIN peer review -

Investigation number: AO-2014-044


Investigation status: Completed
 

• Final Report
  
  

Final Report

Download Final Report
[PDF: 988KB]
 

 
Alternate: [DOCX: 1.82MB]
 

What happened


At 1253 Central Standard Time on 27 February 2014, a Boeing Company 737-8FE, registered VH-VOM (VOM), was radar vectored when outside controlled airspace, near Darwin, Northern Territory. Radar vectoring outside controlled airspace was not permitted, and may have brought VOM into conflict with aircraft that were unknown to air traffic control.

What the ATSB found


The ATSB found that weather in the Darwin area resulted in the majority of inbound aircraft diverting around storm cells. These diversions increased workload for the Approach East controller. The increased workload resulted in the controller using non-standard phraseology and not cancelling radar vectors prior to VOM leaving controlled airspace. Additionally, the flight crew of VOM had not reported ‘clear of weather’ as expected by the controller. This resulted in a lack of shared understanding between the flight crew and the controller.

What's been done as a result


Following this occurrence the Department of Defence introduced theoretical and simulator-based training to assist air traffic controllers to resolve unusual situations using clear communication and direction. The training reinforces positive and assertive control measures, skills that are especially necessary in high workload situations.

Safety message


This occurrence highlights that effective communication is essential for a shared understanding between flight crew and air traffic controllers. On this occasion, the use of non-standard phraseology by both parties resulted in different expectations and delay. Additionally, coordination between controllers is an essential component of their duties; however, this is not transmitted via radio. As a result, silence on an air traffic control frequency should not be interpreted by flight crew as an indicator of low workload for the controller.

For what seems to be a significant breakdown of ATC (Military) procedure, this report seems to lack emphasis on the significant safety issues identified in the investigation. Also note that the only 'safety action' record is in the summary above i.e. What's been done as a result.

MTF...P2    

[Gobbledock]

In my opinion this is yet another serious incident with yet another light and fluffy ATsB report. Nothing in that report got my loins stirring, sorry.

Peetwo;

" Also note that the only 'safety action' record is in the summary above i.e. What's been done as a result".

Agreed. Exactly, 'what' has been done as a result? And in regards to 'what' has been done as a result, has the 'fix' been revisited so as to ensure it is actually working effectively? If the answer is 'no' to any of these musings then this incidents 'loop' remains wide open, so much so that you could fly a  737-800 through it!

Mi mi mi mi

[Kharon]

Point of order M’Lud.

The ATSB report – HERE – details an engine fire event suffered by one of Cobham’s RJ 100 fleet.  The warning systems and aircrew have all worked well and the aircraft was returned to base.  Good job and well done all around.

Naturally enough, everyone wants to know the why’s and the wherefores, so there is an investigation and now, the report.  It is a good effort from the ATSB and provides an example of just how fine a line ATSB investigators must tread when dealing with ‘liability’.  On first reading the report, I thought ‘well – OK, but what’s the upshot, where’s the conclusion? Until you realise that apart from providing the facts and reporting the analysis, ATSB cannot make matters much clearer than they did, even a lay person can see the potential for legal nightmare; and, had the ATSB drawn inference or conclusion, well you can see the dilemma. So well done that ATSB investigator.

Now Ben Sandilands over at Crickey has written an article on the PLANE Talking blog which is ‘interesting’ in that it mentions the CASA response to the incident.  Have a read of the ATSB report, then the article.  I can’t see why CASA would want to become embroiled in a prosecution, I can, just, see Ben’s point, but I fail to see anything of value other an expensive legal nightmare resulting from direct action by CASA – in this case.  

Anyway – FWIW, if time allows, have a scamper through both: personally, I think I may have to agree to disagree with Ben on this one.  Handing over.

Toot toot......

[Peetwo]

CASA & 'just culture'  - Fantasy or fact? 

Yes indeed this is an interesting one...

"K" said - Now Ben Sandilands over at Crikey has written an article on the PLANE Talking blog which is ‘interesting’ in that it mentions the CASA response to the incident.  Have a read of the ATSB report, then the article.  I can’t see why CASA would want to become embroiled in a prosecution, I can, just, see Ben’s point, but I fail to see anything of value other an expensive legal nightmare resulting from direct action by CASA – in this case.  
Anyway – FWIW, if time allows, have a scamper through both: personally, I think I may have to agree to disagree with Ben on this one.  Handing over.

This has also flowed through to the comments, with a bit of a ding dong going on between Fred & Ben.. :  

Ben Sandilands
3 hours ago

Fred, You've read the full report but somehow missed the safety message. Whatever the antecedents of a part, Cobham had to ensure the engine was repaired in accordance with the manufacturers procedures. They didn't. They are responsible for any consequences.



Dan Dair
1 hour ago

Does the ATSB report specifically say that they've trawled through all the previous owners documentation for this airframe & this specific engine.? How could Cobham's engineers weld-repair a combustion chamber wall without being fully aware of what the tolerances are for that repair.? Is it even appropriate to weld that area of the combustion chamber in that fashion.? Is there perhaps a repair plate which would include the welded boss so that the original weld is not being welded-over. (My limited experience of general (as opposed to aviation-grade) welding, is that the action of welding can make the surrounding area brittle & liable to cracking)


Fred 34 mins ago

Dan, Yes, the aircraft's past maintenance records were examined, but the records for the combustor housing only went back as far as 2005, when the housing was installed in the engine. There is no suggestion that Cobham's engineers were responsible for the errant weld-repair. If there was, then I'd imagine CASA would have plenty of grounds to pursue Cobham. According to the report, the last time that heavy maintenance took place was in 2009, before Cobham owned the aircraft. The investigators could not determine the timing of the dodgy repair from the maintenance records. There were three repairs, two of which only came to light through metallurgical analysis following the incident. One repair was documented properly and was performed in 2005, but the other two were undocumented and could have been done some time before or after 2005. According to the report, weld-repairs are approved by the engine manufacturer as a technique for repairing cracks in the combustor housing.

The problem, however, wasn't the weld; it was the grinding that was done afterwards that significantly reduced the thickness of the housing.


Fred

2 hours ago

Thanks for the condescending reply, but that still doesn't answer the question. In the real world, how was Cobham supposed to know that a dodgy repair had been performed on the engine? How could they possibly ensure the engine was repaired in accordance with the manufacturer's procedures if they had no way of knowing about the defect?

Dan Dair

59 mins ago

Fred,

I had this same conversation on the Virgin ATR "tail" incident pages.

It is apparent that, under Australian law, the airline and not the maintenance company, is primarily responsible for the condition of their aircraft.

That is not the way I had presumed it to be.

It remains the case that the maintenance company would be responsible in law for their failures, but the airline ultimately "holds the baby".


Fred

5 mins ago

Absolutely Dan, and I have no problem with that. But realistically, what would CASA achieve in terms of improving safety if it chose to pursue Cobham over a dodgy repair the company didn't perform and didn't know about? It gets back to that "just culture" thing. Ben said that a just culture is "supposed to be about protecting confidences in safety reporting", but that's only a small part of the story. A just culture was defined by James Reason as "atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour". A just culture recognises that human beings are fallible and sometimes make mistakes. It encourages the open and honest reporting of such mistakes in order to improve the safety system, without fear of retribution. Nevertheless, it does not tolerate wilful misconduct.

In Cobham's case, it seems highly likely that this incident occurred through no fault of its own. If CASA pursued Cobham, it would send a very negative message to the industry. Nothing would be achieved in terms of improving safety outcomes and it would probably mean that other companies and individuals would think twice before reporting safety issues. Would that benefit the travelling public? I think not.

Mark Skinner
34 mins ago

Fred, the question should rather be whether or not Cobham could have seen the repair under the manufacturer's maintenance and inspection schedules.

If it could have seen/detected the repairs, then it is totally responsible, not only in law, but also morally. Because if it saw the repairs, but could not establish, for the reasons you pointed out, whether they were done correctly, then it should have had those repairs redone so that they COULD establish that they were done correctly.

The only out that Cobham might have morally is if those repairs were not detectable before the incident.

Perhaps Ben is overreaching with this one but again I think there are greater messages in here that are sadly being missed.
However first to this incident, IMO the best part about this report is that for once we are not talking about the ATSB - i.e. they have actually done their job and clearly stated the facts as presented...
For mine the key to this incident and the 'just culture' message is in the following passage from the Final Report:

In terms of Cobham Aviation Services Australia’s conduct of the most recent 500-hourly on-wing engine inspection, it was reasonable that, if the crack existed at that time, it was not visually-identified as:



• the crack was non-penetrating, meaning that it would probably have only been identifiable when the CTM was fully-disassembled (such as at a scheduled heavy maintenance inspection)



• there were no other, more usual, indications of a crack in the CTM, such as:



- increases in the engine condition trend monitoring data parameters



- blacking around any crack edges due to combusted gas leakage or fretting.



In addition to the lack of visual clues, the maintenance personnel were probably not expecting to find a crack. Human attention is guided by two factors:



• expectancy, where an individual will look where they expect to find information



• relevance, where an individual will look to information sources relevant to the important tasks and goals they need to carry out.



The key factor is expectancy. It is well demonstrated that people are more likely to detect targets when expected, and less likely to detect targets that are not expected (Wickens and McCarley, 2008). This occurs even when the targets are salient, potentially important and in an area to which the person is looking (Chabris and Simon, 2010).

We should also not overlook the 'safety actions' in response by the operator:

Cobham Aviation Services Australia



As a result of this occurrence, Cobham Aviation Services Australia (Cobham) undertook a number of safety actions to identify and capture defects of a similar type prior to their developing into an incident or accident. In addition, Cobham issued the following Technical Service Instructions (TSI):



• TSI-146-72-0015, issue 1 on 17 September 2014. This TSI stated that a detailed visual inspection for cracks was to be performed on each of the four combustion housing welded bosses across the Cobham fleet of ALF502R, LF507-1H and LF507-1F engines.

The compliance date for this TSI was 7 October 2014.



• TSI-146-72-0017, issue 1 on 21 April 2015. This TSI required a non-destructive Fluorescent Penetrant Inspection for cracks on each of the combustion housing welded bosses. This included the four combustion housing welded bosses, two drain valve bosses and the four igniter bosses on all of Cobham’s ALF502R, LF507-1H and LF507-1F engines. The compliance date for this TSI was 1 June 2015.



Cobham reported that of the 53 engines inspected, none had cracks in the location of the combustor housing combustion liner locating pin welded boss welds. However, seven previously-unidentified cracks were identified at the location of the ignition boss, which is also part of the combustor housing. Those cracks were routinely-managed in accordance with the manufacturer’s maintenance manual.

Now back to what is IMO the central issue to Ben's article that is now causing debate & contention in the ensuing commentary. 

First the background. Ben Sandilands has witnessed for many decades the administration of the Oz aviation safety system being manipulated, obfuscated, abused, historically tarnished, neglected etc..etc; by a rampant, seemingly untouchable bureaucracy that governments of either colour totally abscond from proper oversight or governance.

So naturally, like much of industry (refer ASRR report), Ben's trust quotient & 'bollocks' alert will be rapidly pinging when it comes to the regulator making comments like..

"...We also have system based on just culture to ensure open reports such as are made to the ATSB and mistakes rectified..."  

Until proven otherwise "just culture" & CASA in the same sentence will be met with much scepticism from an industry (including some aviation journos) that have been bullied, belittled, badgered and embuggerised by the "Iron Ring" big "R" regulator and supporting department for the best part of three decades...

Seaview...Lockhart...PelAir cover-up...Mildura Fog duck-up...VARA ATR bird strike abberration...the list & the bollocks continue - miniscule Chester please take note of what IMO is the most important part of Ben's article:

The new Minister Darren Chester is meeting the grass roots aviation industry in Tamworth this Friday, one hopes before the government goes into caretaker mode on the calling of a general election.

It is an important meeting. It is also important for the Minister to note that his predecessors were treated with arrogant contempt by his department in relation to aviation matters and public safety, and that taking visible control of his portfolio and remembering he is a representative of the people, not unaccountable bureaucrats or corporate entities, is a prerequisite for being held in respect.

 

MTF...P2

Ps

VH-NJI in-flight fire damage



Source: Jason Grimmett

Gotta wonder where all those bits happened to land -

[Peetwo]

CASA & 'just culture'  - Fantasy or fact? 

..Now back to what is IMO the central issue to Ben's article that is now causing debate & contention in the ensuing commentary. 

First the background. Ben Sandilands has witnessed for many decades the administration of the Oz aviation safety system being manipulated, obfuscated, abused, historically tarnished, neglected etc..etc; by a rampant, seemingly untouchable bureaucracy that governments of either colour totally abscond from proper oversight or governance.

So naturally, like much of industry (refer ASRR report), Ben's trust quotient & 'bollocks' alert will be rapidly pinging when it comes to the regulator making comments like..

"...We also have system based on just culture to ensure open reports such as are made to the ATSB and mistakes rectified..."  

Until proven otherwise "just culture" & CASA in the same sentence will be met with much scepticism from an industry (including some aviation journos) that have been bullied, belittled, badgered and embuggerised by the "Iron Ring" big "R" regulator and supporting department for the best part of three decades...

Seaview...Lockhart...PelAir cover-up...Mildura Fog duck-up...VARA ATR bird strike abberration...the list & the bollocks continue - miniscule Chester please take note of what IMO is the most important part of Ben's article:

The new Minister Darren Chester is meeting the grass roots aviation industry in Tamworth this Friday, one hopes before the government goes into caretaker mode on the calling of a general election.

It is an important meeting. It is also important for the Minister to note that his predecessors were treated with arrogant contempt by his department in relation to aviation matters and public safety, and that taking visible control of his portfolio and remembering he is a representative of the people, not unaccountable bureaucrats or corporate entities, is a prerequisite for being held in respect.

 

MTF...P2

Ps

VH-NJI in-flight fire damage



Source: Jason Grimmett

Gotta wonder where all those bits happened to land -

Following on from my post above the commentary & mudslinging between Ben & Fred continued until this...

Ben Sandilands
May 7, 2016 at 8:30 pm
Fred,
CASA isn't ever justified in ignoring the law, as it did in the Pel-Air saga, or treating the executive branch and the people of Australia with arrogant contempt. It's statement in relation to Cobham was a total nonsense, in that it completely contradicted its position on Tiger Airways.
This is an agency that doesn't have the capacity to overhaul aviation regulations even to its own timetable, and let 15 people die in the Transair disaster because it knew the airline was dangerous yet elected, as per its Senate committee evidence, to take no action, contrary to its obligations under the law, and without warning the public.
You are in the wrong place if you think I'm going to ignore its resolute unwillingness or helplessness when it comes to being an effective safety regulator.
[/url]
 

Fred
May 8, 2016 at 11:36 am
Nobody asked you to Ben, but how about a little balance?
CASA's failings are well documented. What do you propose as a solution to improve the safety culture in Australia? On the one hand you imply that James Reason's methodology should merit more respect, and yet on the other you seem to advocate the punitive culture that Reason and others reject.
I'll reframe the question I asked earlier: Do we want a punitive culture that is likely to encourage individuals and organisations to hide their mistakes; or do we want a culture that encourages open and honest reporting, but at the same time does not tolerate wilful violations or reckless behaviour? Surely the answer is obvious.

 


Ben Sandilands May 8, 2016 at 12:58 pm Fred, I'm on the side of those who want an accountable culture in the public administration of air safety in Australia. An administrative branch that is subordinate to and the servant of the executive branch. In other words, one that is appropriate to a parliamentary democracy, not some tin pot third world state. What do you stand for we might wonder? Just a string of excuses for practices that undermine air safety. If you were to better inform yourself about the current situation in this country you'd know that Australia has policy settings in aviation that are contrary to those endorsed by ICAO and the NTSB and FAA in some areas, and put commercial expediency above all other considerations, including the direction taken by James Reason. 



Fred

[url=http://blogs.crikey.com.au/planetalking/2016/05/02/cobham-jet-caught-fire-after-company-failed-to-properly-repair-an-engine/#comment-39342]May 8, 2016 at 1:24 pm

I am very well informed with respect to safety regulation in this country, thank you. As a professional pilot, my safety depends upon it at least as much as yours and other members of the travelling public. My comments were not aimed at making excuses. They were intended to put a few things into perspective with a view to finding a better way forward than constant harping that does nothing to improve safety.

You have made it abundantly clear that dissenting opinions are not welcome at Plane Talking. That is a very great shame, given the limited discourse on aviation matters in the media here in Australia. Perhaps you'll be glad to know that I will not be adding my comments to any further discussions.

And so the to & fro, quid, pro, quo inevitably drifted to an end ; that is until P9 chimed in with this: 

Sam Jackson
May 10, 2016 at 7:08 pm
Now, when everyone has finished banging their drums; can we have a look at the realities? For example a flawed design which requires constant repair to peripherals. This engine section (component) has, in what, 10 short years often needed ‘repair’. Clearly, if the lug is in need of constant monitoring and a repair protocol, the underlying reasons for that need examination. I think we all have a fair idea of what happens within and the pressures it’s subject to of a ‘combustor’. Furthermore – if a 0.002 thickness of metal is the difference between flame in and flame out, then there is an inherent problem in the design specification.

There may be flaws in the system for checking and recording repairs, there is in every system. But – reality is a prospective buyer cannot, nor will a survey engineer on a ‘pre-buy’ inspection take out a micrometre and check the thickness (or lack thereof) of every ‘skin’ in the aircraft. The ‘grinding pass’ may well have been a couple of thou too much – but how could Cobham, or anyone else for that matter have known? The lug ‘repair’ prescription is a result of inherent faults within the combustor liner design. If, indeed there is an existing design fault, then how is it to tracked back to the designers weight/ cost allowance tolerances, let alone to the apprentice welder with a grinder. No: this dog won’t hunt – what of cracks in the combustion layer, which lead to lug failure, which lead to fine tolerance grinding, which start engine fires? Only one place to look foe answers.

To which Dan Dair replied:

Only one place to look foe answers.

Log in to Reply

Dan Dair
May 11, 2016 at 6:59 am
Sam Jackson,
Now that you’ve got-down off your own soapbox….. (joke)
Can I ask a question of you, which I alluded to with Fred.?
How big a problem has this particular issue been with these Honeywell engines.?
The fact that Honeywell had an inspection regime in place AND had requirements specified for welding repairs would imply that the problems surrounding the liner & bosses is well-known to the manufacturer.?
On the other hand, the ATSB report appears to suggest that there isn’t any significant history of actual failures which relate to this engine-type.?

NB. I agree completely about the 2-thousandths tolerance-deficit. Sure, it’s out of tolerance, but as I said earlier, it’s flown for ages with no apparent problems. The idea that the 2-thou’ makes all the difference is a bit rich to me.? That statement would imply that it is inevitable that the liner MUST fail if it is out of tolerance.?
Surely if that IS the case, it would make more sense to have made the liner a couple of millimeters thicker in the first place, or perhaps they ought to have specified that welded repairs were unacceptable ten or more years ago, when this particular problem was already apparent.

I then followed in with quoted parts of my post above, to which finally (to this point ) P9 replied to Dan Dair (& myself) with this excellent & balanced posted comment:

Sam Jackson

May 11, 2016 at 7:26 pm
(Smile) – Nay, not a soap-box Dan; ‘tis but a small stump. The ATSB investigator has, as P2 defines it, not done too shabby a job in this report. Honeywell had and still have a procedure in place to deal with a ‘known’ potentially weak area; and, that procedure has stood the test of time. I have no doubt that amendments now in place will adequately cover any other potential trouble spots their skilled engineers and experts may discover. Company reputations and profits depend on the ‘manufacturer’ getting it right – every time. The pressures and temperatures within the combustion section of a modern jet engine are insane; these engines have been in service a long time now and there can be little doubt the repair, done when required, as specified, has been effective. ATSB do reflect this in their report; mark you they have no skin in the game; their report also reflects that. Hopefully, Greg Hood will be able to stop the downward trend and PC outcomes we have seen the last half decade.

But CASA – well that is a horse of a different colour. Personally, I don’t believe there is much in this one incident, to get them reaching for the big R book and hammering the company. It could even be that the company was as much sinned against as it was sinful. Caveat Emptor has long been a hard held tenet of aviation traders, for bloody good reason. No, the beef is with the cynical CASA point scoring, by claiming, all of a sudden, that a ‘just’ culture is in place. Bollocks. Just when it suits and only when it suits is much nearer the truth. Close observers know that this is just another cycle in the no change to policies of strictly no liability, responsibility or accountability. It has been thus for at least three decades I have witnessed. This will not be allowed to change under the current lunatic running the asylum.

So, we have a known, high stress engine area which, occasionally, needs careful, concise, proper repair. We have a manufacturer doing all the right things. We have an ATSB report which, in the main, is acceptable. Then we have the CASA ‘touchy-feely’ response. Now a cynic would (quite rightly) say that CASA would not dare upset a company like Cobham, in any event. The notion of annoying a big hitter like Cobham – when they probably have the ‘law’ on their side becomes unthinkable. A cynic could say that ‘just culture’ is just buzz words, written on the dunny walls, but Gibson is silly enough to use it, after a non event to score much needed Brownie points. Two thou’ does not a law suit make – IMO. Right then; off the stump and back to my knitting, having spent my two bob as best pleased me.

  
MTF?- Yeah I reckon...P2

[Peetwo]

Ben Sandilands getting up a head of steam -

Following on closely from the PT Cobham BAE-146 blog piece & the 50 odd comments that followed, Ben Sandilands has yet another 'serious' Jetstar incident to sink his teeth into to again highlight the appalling duplicity & selective bias by the inept, seemingly captured big "R" regulator CASA.

This ATSB investigation will also be interesting in that it could be regarded as the first real test for the soon to be Chief Commissioner Hoody to insure a totally non-PC'd final report is produced, warts & all.       

For background here is a rehash of the 'other' Jetstar incidents that were also covered by AP & PT...  

AAI in a parallel universe - Will Aviation Safety again be the victim of Bureaucratic obfuscation & Political expediency..

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

From the 'Closing the safety loop' thread & yesterday's ABC radio 'World Today' program:

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.

Vivid memories of the last high profile 'parallel' investigation and we all know how that turned out -

Wonder if the operator will voluntarily ground all A320 operations until all the safety issues are effectively risk mitigated to the satisfaction of the regulator? - Yeah right & Elephants can fly  (see pic above)

[/url]  
Continued from ABC World Today program:

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.

Ben Sandilands again with a follow up article:

Comment: Why action should be taken against Jetstar

Ben Sandilands | Dec 04, 2015 5:48PM |

A Jetstar A320, does the airline really give a damn about your safety?

The incidents involving missing loading data and an out of balance takeoff by Jetstar are evidence that the airline and its safety regulator CASA cannot be trusted to ensure passenger safety.

Jetstar [url=http://blogs.crikey.com.au/planetalking/2015/12/04/two-serious-jetstar-incidents-under-atsb-investigation/]twice dispatched jets in a compromised safety state from different Australian airports within 10 days in October.

Its actions in relation to the second incident posed a major threat to the life of all on board the A321, which was configured with more than 215 seats.

At the very least CASA should do what it did during the rehabilitation of Tiger Airways, and restrict the number of sectors it can fly for however many months it takes for the airline to demonstrate 100 percent compliance with the safety regulations it clearly held in such contempt in these incidents.

There is something seriously wrong with the safety culture of the Qantas low cost subsidiary, and its often repeated claims that ‘safety is its No 1 priority’ is a lie, since if that was the case it would never attempt to push out flights from airports in such unsafe states that in one incident at least the ability of the jet to actually complete its takeoff was in doubt.

The statements that came from the airline and CASA today avoid dealing with the obvious. It’s no good saying ‘we will ensure this never happens again’ when the airline and the agency failed completely to prevent these almost unbelievable breaches of sound operational practice in October. Airlines don’t become dangerous and unsafe overnight. If CASA didn’t know what was going on before this situation arose it should be urgently restructured with competent and committed safety professionals. If it did know, an explanation for its inability to prevent these risky incidents happening is urgently needed.

What was going on its Jetstar to allow a jet to begin moving away from a terminal when the pilots were unaware of the true state of its loading and the disposition of the passengers in relation to the operational limits in the approved flight manual?

How focused were Jetstar’s contractors or direct employees on meeting KPIs when they are overlooking the one that should be up there in lights at all times, which is to keep passengers safe. No-one who has safety top of mind would have dispatched either of these Jetstar single aisle airlines in the state they were in when the doors closed.  But it happened twice at different major Australian airports in the same month.

It doesn’t matter if the blame for these errors resides with company employees or contractors either, Jetstar senior management, and for that matter the entire senior management of Qantas and its board are personally liable in Australian law for the safety of the operations they control and conduct.

These two incidents involve a gross contempt for or ignorance of Australian standards. One of them could by now have been the subject of a Royal Commission or judicial inquiry similar to those that followed three Ansett ANA group Vickers Viscount crashes and one TAA Fokker Friendship tragedy over a period of years from the late 50s into the 60s.

These Jetstar incidents were inexcusable. Had the Melbourne incident ended in tragedy CASA would be in the box being grilled as to how it had exercised oversight of Jetstar, and what findings it had made and what remedies it was attempting to enforce.
No-one should trust their lives or those of their loved ones to Jetstar until the most thorough investigation establishes why it disregarded safety so blatantly in these incidents, and how it is demonstrated that it has comprehensively reformed its practices and ensured that it employs persons with a clear and testable competency in putting safety first.

Again followed by some excellent observations:

1
comet
Posted December 4, 2015 at 7:24 pm | Permalink
The travelling public should be aware that Jetstar is an unsafe airline, running on third world standards of operation.

Politicians across the land should understand that they are responsible for turning Australia’s air safety authority, CASA, into the useless waste of funds that it has now become.

We now have cowboy airlines with no oversight. We can only hope the FAA degrades us into a category 2 backwater.

2
Creeper
Posted December 4, 2015 at 8:28 pm | Permalink
I’d like to see what Tony Davis has to say about this.

One could hope Nick Xenophon is all over this .

3
Damo
Posted December 4, 2015 at 8:39 pm | Permalink
This is what happens when the tail wags the dog and the industry is allowed to be dumbed down and airlines farm out operational jobs to the lowest bidder.

That is not to say the larger airlines don’t do it but the turnover of poorly paid staff by the contract companies only adds to the problem here.

4
Dan Dair
Posted December 5, 2015 at 9:40 am | Permalink
Questions;
Is CASA actually ‘in the pocket’ of the airlines,
or is it merely ‘too close’ to them & consequently finds itself in-agreement with what the airlines do, rather than robustly questioning airline policy.?

Are the politicians &/or Civil Servants really as unaware of the apparent state of (lack of) oversight of Australian aviation as they appear.?

Or, are they attempting to maintain their distance from CASA,
assuming therefore, that they know it’s a problem which needs fixing but don’t believe that they can justify to the public the necessary level of funding to achieve this outcome.?
Would the ‘shock’ of an FAA downgrade have the desired effect of focussing the minds of the appropriate ‘leaders’ on this problem.?

And is this the only way that we can imagine that CASA & the Australian government will actually get a grip of this ongoing problem & resolve it.?

(or will the government decide it can manage very well thank you, as a category two nation.?)

 
P2 comment: The mention of Nick Xenophon is extremely relevant because at a pivotal point in the Pilot training Senate Inquiry, when NX was zoning in on the dodgy safety culture of Jetstar (*1) - somewhat conveniently?? - CASA with very little warning took the bold step of grounding Tiger -

(*1 - Remember "Toughen up Princesses" & Ben Cook Darwin base Fatigue Special Audit report?)  

OK...so one more time round the Mulberry bush..  

&... TICK TOCK goes the Miniscule clock??

Ben S courtesy of Planetalking today:

Why Jetstar's latest incident should alarm flyers
The ATSB says a 'serious incident' is one that could end in a crash, and Jetstar has just had another one

Ben Sandilands
Jetstar’s tail strike incident at Melbourne Airport this week puts another red flag over the Qantas subsidiary’s operations and the unwillingness to date of the supposed safety regulator CASA to ground or restrict its flights.

However the ATSB appears to have fast tracked its inquiry into an incident that imperiled the lives of those on the 180 seat passenger jet bound for Hobart, indicating a final report will be provided by this November.

Under previous direction the ATSB has botched and now delayed its attempts at a PelAir crash inquiry (2009) and proven incapable to date of dealing with an astonishing situation where Qantas and Virgin Australia 737s were forced to land in blinding fog with low fuel at Mildura in 2013, and an appalling screw up that caused serious undetected structural damage to a Virgin ATR turboprop in regional service in NSW in 2014.

The ATSB has abundant reasons from the recent operational history of Jetstar for its speedy reaction.

In October last year another Jetstar single aisle Airbus, this time a 215-220 seat A321 was dispatched from Melbourne Airport in such an unsafe loading balance condition for a flight to Perth that it struggled to become airborne.

The same month Jetstar dispatched an A32o from Brisbane for Melbourne 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.

These two October 2015 incidents perforce demonstrated that Jetstar, an Australian licensed subsidiary of Qantas, had lost on two occasions the absolutely essential prerequisite of safe operations of knowing how jets were loaded and that the distribution off passenger numbers and below floor baggage or freight was within the approved safe limits that are found in the flight manuals of all jet airliners.

These incidents raised questions of safety culture in Jetstar that have not yet been answered by an ATSB inquiry, nor addressed by CASA, the gutless safety regulator that conducted a grandiose grounding of Singapore owned Tiger Airways in 2011 after it infringed safe minimum altitude requirements over the Leopold estate near Geelong during a night time go-around at Avalon Airport.

CASA was justified in grounding Tiger, but was it justified in treating Jetstar with comparative indifference over a series of equally disturbing incidents at Melbourne, Cairns and Singapore Airports in earlier years?

The response of CASA to persistently unsafe practices or attitudes by Tiger was to first ground the carrier, and then restrict the number of sectors it could fly each day until it acquired a safety culture and a respect for the regulations.

The safety culture of Jetstar ought to be in the dock of public opinion over the October 2015 incidents, and as the ATSB says in its notification of an investigation, the loading data for last Wednesday’s flight will be part of that inquiry.

Tick tock goes the miniscule clock??

MTF...P2

[Gobbledock]

Ben is 100% spot on

Loading incidents are nothing new at Jetstar. Since 2004 there have lots of incidents involving incorrectly loaded containers, out of trim aircraft, Oleo's extended and aircraft damaged by GSE (tears in the fuselage). There has been several A320 takeoff's in which the nose has remained heavy and not wanted to lift off and others where the tail has almost struck the runway due to the aircraft being tail heavy and nose light, opposite to the pilots paperwork. I've observed ground crew doing things that would make your hair turn silver. But that is the low cost model that has been accepted by the airline as well as the Regulator. CAsA are scared to confront JQ due to the power of the QF Group, so incidents like these don't surprise me, and neither will they cease IMHO.

As for the ATsB, well they have the capacity to investigate these incidents independently and issue a transparent report, but to date they have treadles cautiously around anything involving the Rat. Hoody knows this political game well, he worked in the upper echelons of Fort Fumble and he knows how precious the Rat is to the politicians. Whether his approach now change is a different story, one that only time will tell.

One thing is certain - when it comes to aviation standards the bar has always been set extremely low. The Jetstar model has always skirted with the bottom of the barrel. Fatigued international flight and cabin crews, the desire to shove Indian cadets with 20 hours into the R/H seat, muppets on ramp with minimal experience loading aircraft, outsourcing load
control/JOC functions to third world countries, JQ management will stop at nothing to turn a quick buck and earn their executives fat bonuses.

I've said it before and I will say it again - it's all fun and games until somebody gets hurt. CAsA has a role to play in all of this, and it is not doing it very well at all.

Tick tock Miniscule

[Peetwo]

MH370: ATSB & the search for IP going global  - Part I

From off the MH370 forum:

Take two and action -

From ABC radio's World Today program:

MH370 search to be called off, recriminations likely after new book on disaster
Peter Lloyd reported this story on Tuesday, May 17, 2016 12:24:00
About JW Player 6.11.4923 (Ads edition)
        
  MP3 download
KIM LANDERS: When the search for missing Malaysia Airlines flight 370 began off the West Australian coast more than two years ago, the then lead investigator, former defence force chief Sir Angus Houston, described the attempt as 'the most difficult search in human history.'

Now that search in the remote southern Indian Ocean is almost over.

Families of the 239 people on board want it to continue, but the Governments in Malaysia, China and Australia are sticking to the plan to wind up the search by the end of July if nothing is found.

But as Peter Lloyd reports, confirmation of that deadline has stirred debate about whether the massive search has been in the wrong area, despite clues that the jet crashed elsewhere.

PETER LLOYD: It's a place sunlight can't reach. Dark, distant, freezing cold. The southern Indian Ocean has refused to give up the wreck of MH370.

The Australian Transport Safety Board chief commissioner Martin Dolin is convinced the plane is out there, but the search is almost done with nothing to show for it.

MARTIN DOLAN: The Governments have commissioned us to cover up to 120,000 square kilometres, we've got about 15,000 square kilometres of that to go.

PETER LLOYD: Barring a discovery, the hunt will end around July, a milestone moment when Australia becomes the custodian of a new world record: supervisor of the most expensive failed search in the history of aviation.

Martin Dolan again. -

MARTIN DOLIN: The Australian Government has given us $60 million and the Chinese Government has given us about $20 million, the total cost is about $180 million, if we have to complete the entire search area.

PETER LLOYD: What is the current thinking about, the confidence you have about whether you're even in the right place?

MARTIN DOLIN: We always said that it was a matter of probability, not certainty, that the aircraft would be found in the area we are searching.

PETER LLOYD: Malaysia Airlines is state owned, it magnifying the loss of face attached to the possibility that one of its pilots is a mass murderer. Suspicion has never quite lifted from the captain and co-pilot.

To aviation writer Christine Negroni, it's been a huge scandal from the get-go, and it's not just Malaysia at fault.

She's written a book that uncovers vested interests competing to shape impressions, from Boeing, to embarrassed defence officials.

CHRISTINE NEGRONI: There were different camps. The investigators arrived at the scene and they would see certain things that they had seen before in previous investigations and it all seemed quite logical and normal.

The law enforcement people would come to the scene and they would see things that were new to them, they don't investigate plane crashes, they investigate crime.

I think the Americans wanted to be involved, American law enforcement, and I think the Malaysians were not exactly welcoming the assistance of the American law enforcement.

And I think the only way the Americans thought that they could sort of push their way in there was to raise more, you know, suspicions in the general public imagination that this was a criminal act.

PETER LLOYD: At the start of the investigation, reports from unnamed sources in the American aviation sector spearheaded the finger pointing at the pilots, just as Malaysians were discovering the staggering incompetence of defence forces that Saturday night.

CHRISTINE NEGRONI: A triple seven was flying across the Malaysian peninsula off track, off course, off radio communication, perhaps off radar, definitely off radar transponder radio, headed towards Kuala Lumpar towards the Petronas Towers.

I mean that's a huge, frightening lapse in security and radar and air traffic control and, you know, in every respect that's terrible.

PETER LLOYD: By law, a crash investigation must be completed by Malaysia, but the Government says its hamstrung by Australia's failure to find the plane.

Christine Negroni believes that is a bogus claim, and worse still, she claims the crash investigation underway right now in Malaysia is a sham.

CHRISTINE NEGRONI: There is no evidence that this is more than just somebody saying, "Oh no, no, no - it's fine don't worry about it, move on.

PETER LLOYD: Who's going to hold them to account?

CHRISTINE NEGRONI: Well, and that really is the tragedy here, because I think because the aeroplane has not been found and may not be found, there is no sort of calling to account Malaysia.

Malaysia can simply sit back as it has and say without the aeroplane, we can't ever know. And that will be I think the, sort of, the conclusion of Malaysia 370; always a mystery, no-one will ever know and we don't know whether that is true.

KIM LANDERS: Aviation writer Christine Negroni ending Peter Lloyd's report.

Also today from Christine Negroni:

[*]Independent Investigators and Malaysia 370
May 16, 2016 / Share your comments...

MH370 wreckage analysis included comparison of stenciling.

My post on Forbes.com last week suggesting the number of clues on the ground that could shed light on what happened to Malaysia Flight 370, generated much interest but particularly the suggestion that a new independent group be selected to give a fresh eyes view to the case. This idea came from Peter Fiegehen, an air traffic control specialist from Australia who also worked with the Australian Transport Safety Bureau. Peter suggests a small team not previously connected to the investigation could be effective.

The problem is that ICAO Annex 13 which provides guidance to air safety authorities can be interpreted in such a way that it excludes outsiders. “States shall” investigate, the document states. But states can also “delegate“. The ICAO Annex is a compilation of standards and recommended practices. They are not cast in stone. The air accident investigation document is nearly always in a state of revision including one that goes into effect later this year.

In addition, countries are free to file their own exceptions from the ICAO standards. For example the United States makes public the transcripts of cockpit voice recorders which until the latest amendment, were not to be disclosed outside of the investigation.

What is encouraging about the revision of Annex 13 is the recognition that things change and never more so than now with the digitization of the air transport system.

Where international aviation authorities need to be faster on the uptake is in appreciating the value of crowd sourcing of information following air accidents. More people from technical specialists to intelligent onlookers have the means to contribute and that is a good thing. The established tin-kickers must not be threatened. Their own expertise is not diminished because outsiders can sometimes offer value.


An air safety conference in Adelaide in 2014

Every year I attend the meeting of the International Society of Air Safety Investigators I am both impressed and frustrated by what is the two sides of the same coin. The specialists are knowledgeable in their specific areas which is good but closed-minded to the point of dismissive of the contributions of outsiders, which is not good.

Peter Fiegehen recognizes that “group-think, peer or other pressure” and “false hypothesis factors” now infect the official investigation into the mysterious disappearance of MH370. His idea of hitting the reset button is worth consideration. If an agency as cumbersome and bureaucratic as the UN’s ICAO sees the benefit of regular revision, what excuse is there for the resistance of agencies investigating one specific accident?

http://christinenegroni.com/independent-investigators-malaysia-370/

[*]

The above article from Christine Negroni is certainly thought provoking in so many ways:

..The problem is that ICAO Annex 13 which provides guidance to air safety authorities can be interpreted in such a way that it excludes outsiders. “States shall” investigate, the document states. But states can also “delegate“. The ICAO Annex is a compilation of standards and recommended practices. They are not cast in stone. The air accident investigation document is nearly always in a state of revision including one that goes into effect later this year...

[*]
 I fear that the Malaysian's (so called Annex 13 MH370 investigation) are using the A13 to effectively manipulate & control the official MH370 narrative, clearly the original intent & purpose of the A13 SARPs were not designed for this purpose -   

..In addition, countries are free to file their own exceptions from the ICAO standards. For example the United States makes public the transcripts of cockpit voice recorders which until the latest amendment, were not to be disclosed outside of the investigation.

What is encouraging about the revision of Annex 13 is the recognition that things change and never more so than now with the digitization of the air transport system...

[*]   
Negroni points to an example where notified exceptions to the ICAO can be for the betterment & continual improvement to the A13 SARPs.

Unfortunately some States, like Australia, use the exception system to lessen their obligations to the SARPs making regressive (vs progressive) steps to helping improve the air safety system in an ever changing world of technology advancement.

Some examples from the 10 pages of Australia's notified differences to Annex 13:

Definitions:

Safety recommendation - 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.

P2 - This fundamental change, to what is largely accepted by nearly all signatory States (including the US & Canada) as best practice to promoting proactive action to address serious safety issues identified in the course of an AAI, came about when Beaker took over the ATSB. This change was in line with Beaker's 'beyond Reason' (BASR - beyond all sensible Reason) philosophy that was IMO one of the major reasons why the 1st PelAir report (& many other significant investigation reports since) ended up being so flawed & biased in favour of the operator, while crucifying the pilot. 
 
Serious incident - Australia requires reporting of ‘transport safety matters’, which, through definitions and reporting requirements in the Transport Safety Investigation Act 2003 and Transport Safety Investigation Regulations 2003 result in matters being reported which are equivalent to those contained in the Annex 13 definition of a serious incident. The Annex 13 definition of a serious incident is used for classifying reports in the Accident Investigation Authority’s database.

P2 comment - This is yet another cynical attempt to subvert the ATSB's obligations to ICAO and in the process subsequently waters down an important ICAO definition:

Serious incident. An incident involving circumstances indicating that an accident nearly occurred.

Note 1.— The difference between an accident and a serious incident lies only in the result.

Note 2.— Examples of serious incidents can be found in Attachment C of Annex 13 and in the Accident/Incident Reporting

Manual (Doc 9156).

&..


Forwarding

4.1 The State of Occurrence shall forward a notification of an accident or serious incident with a minimum of delay and by the most suitable and quickest means available to:

....e) the International Civil Aviation Organization, when the aircraft involved is of a maximum mass of over 2 250kg.

& also..Pg 5. Ch 5 - 5.1.1 to 5.4


"..Australia may not institute an investigation into all foreign or Australian-registered aircraft involved in serious incidents. Decisions on whether a particular serious incident will be investigated will depend on resources and the likely benefit to future safety..."

There are many examples of where the ATSB has defined on their database a 'serious incident', that has subsequently escaped being forwarded to the ICAO international accident & serious incident database (e.g. LOSA or BOS incidents).

There has also been several cases where a 'serious incident', as defined by the ATSB, has subsequently had no investigation initiated, even under the ICAO definition the ATSB would have been obliged to do so...     

[*]
 Back to Negroni article:

..Where international aviation authorities need to be faster on the uptake is in appreciating the value of crowd sourcing of information following air accidents. More people from technical specialists to intelligent onlookers have the means to contribute and that is a good thing. The established tin-kickers must not be threatened. Their own expertise is not diminished because outsiders can sometimes offer value...

[*]
Nowhere was/is this more evident, in a domestic context, than with the 1st & ongoing ATSB Norfolk Is, VH-NGA (PelAir cover-up) ditching investigation. 

..Peter Fiegehen recognizes that “group-think, peer or other pressure” and “false hypothesis factors” now infect the official investigation into the mysterious disappearance of MH370. His idea of hitting the reset button is worth consideration. If an agency as cumbersome and bureaucratic as the UN’s ICAO sees the benefit of regular revision, what excuse is there for the resistance of agencies investigating one specific accident?..

[*]
I find it extremely ironic that we are already talking about; a) the possible "re"-investigation of MH370 by totally independent aviation accident investigators, when the same thing was repeatedly suggested but ignored, with the ATSB announcement and ongoing PelAir re-investigation; and b) that the Dolan led ATSB is inextricably associated with yet another dodgy & possibly corrupt, aviation accident investigation, that appears to be part of a multi-party political/bureaucratic cover-up -


MTF?- Definitely..P2

[Peetwo]

Risk mitigation in the real World

The following is a perfect example of how the Annex 13 AAI process is supposed to work, that is when the State transport safety investigator (the ATSB) is not too busy providing top cover for other aviation safety agencies; or the big end of town industry stakeholders - FDS!

 FAA's FAR 60 TAKES EFFECT TODAY
 
                                                            An FSI COMMENTARY
 
                       
                                                            By Roger Rapoport
                                                            Contributing Editor
 
 

            
The FAA's final FAR 60 rule  https://www.gpo.gov/fdsys/pkg/FR-2016-03-30/pdf/2016-05860.pdf
is effective today. Implemented at an estimated cost of $82 million, the new regulation requires airlines to reprogram their simulators and implement training for high altitude approach to stall and stall recovery.  The ruling takes effect the day before the seventh anniversary of Air France 447, the first of three aircraft lost over the past seven years due to high-altitude aerodynamic stalls. Together these accidents have taken the lives of 506 people.
            
The American carriers must complete simulator reprogramming and pilot training.  under the new rule by March 12, 2019,  Airlines around the world, led by carriers in Europe, Canada, Australia and the Middle East, are expected to follow the lead of the FAA and the European Air Safety Agency on this issue.
            
Some airlines , such as Alaska and Southwest, are moving ahead of the FAA deadline for implementation. A partial response to three commercial airline accidents triggered by high altitude aerodynamic stalls in the South Atlantic, Mali and the Java Sea since 2009, the final rule also makes a strong case for more hands-on stick and rudder training in the age of automation.
            
Learning how to recognize approach to a high-altitude stall and how to recover from a stall is something every pilot must know.  Confusion attributable to the fact that training simulators were incorrectly programmed for this event has contributed to the problem.  Adverse weather is also a key factor. Thanks to the FAA's decision to do live stall tests at cruise altitude on both Boeing and Airbus aircraft in 2014, pilots will be trained to avoid the tragedies that took down Air France 447 as well as Air Algerie and Air Asia planes in 2014.  All of these  lost aircraft were captained by veteran pilots who had never been trained on approach to high altitude aerodynamic stalls or stall recovery.
            
A dramatic example of the training problem was documented by the  Irish Air Accident Investigation unit in its final report on a United Airlines flight approaching Dublin in a major storm on October 20, 2013:  http://www.aaiu.ie/node/921.  Pitot icing produced the same kind of unreliable airspeed that triggered the Air France 447 event.
            
Responding to loss of airspeed falsely shown on his flight display and an incorrect stall warning, the copilot pitched the aircraft down and increased engine thrust. Following a second erroneous stall warning, the copilot pitched down again.
            
After determining that the copilots' airspeed indicators were reading incorrectly, the captain took control of the aircraft and landed the plane in Dublin.  The Irish investigation shows that the copilot had been misled by his instruments, much like the crew of Air France 447.  Lack of a standby angle of attack indicator, routinely installed on most military aircraft and available as an option to both Boeing and Airbus customers, handicapped this aviator.  This device would have helped the copilot understand that his plane was not actually in a stall, despite his corrupted instruments readings and false stall alarms.
            
Fourteen flights attendants and passengers suffered minor injuries. The plane also sustained damage to the central hydraulic system and cabin ceiling panels. 
            
Hopefully implementation of the FAA's final rule will persuade all airlines worldwide to upgrade their simulators and pilot training on this critical issue as soon as possible.
 
 
Roger Rapoport is the producer of the feature film. Pilot Error. http://www.pilot-errormovie.com/pilot-error-dvd/pilot-error-dvd-pre-order
         
Back to Top

  
Meanwhile in Dunce-under land the ATSB is putting out crap like this: Three years for this?? - FDS

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.

[b]Nothing to see here.
[/b]

Quote: This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!



[b]When will we be like the rest of real world and carry technical alternates.[/b]

ATSB Safety Issue No: AO-2013-100-SI-01
 
ATSB Safety Issue No: AO-2013-100-SI-02

ATSB Recommendation No: AO-2013-100-SR-057 

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

Ozbiggles - 3 years later The Mildura report

---

3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

 
No further comment, just disgusted

[Peetwo]

To investigate or not to investigate? - that is the question.

Last Friday at 01:52 EST an incident was reported to the ATSB that apparently they will be investigating??  

Flight below lowest safe altitude involving Boeing 737, VH-XMO at Launceston Airport, Tasmania on 17 June 2016
 
Investigation number: AO-2016-061
Investigation status: Active
 

• Summary
  

Summary
The ATSB is investigating the flight below lowest safe altitude involving Boeing 737, registered VH-XMO at Launceston Airport, Tasmania on 17 June 2016.

While conducting the runway 32 ILS published missed approach procedure, the aircraft diverted off the published heading and flew below the lowest safe altitude.

As part of the investigation, the ATSB will interview the flight crew and gather additional information, including recorded data, as required.
 
General details

General details Date: 17 Jun 2016
 
Investigation status: Active
 
Time: 01:52 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Launceston Airport
 
Occurrence type: Flight below minimum altitude
 
State: Tasmania
 
Occurrence class: Operational
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Jun 2017 
 
Aircraft details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737-376
 
Aircraft registration: VH-XMO
 
Serial number: 23488
 
Operator: Express Freighters Australia
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Melbourne, Vic.
Destination: Launceston, Tas.
 
 
 


Last update 17 June 2016

However there is a couple of points with this incident that are more than passing strange??

To begin the statement that this was a flight below 'lower safe altitude' is misleading as every IFR qualified pilot knows the missed approach procedure for all IAPs is contained within the 25nm (or defined distance) Minimum Sector Altitude. Which for the sector that the 32 ILS missed approach heading of 313° is contained is 3,200 feet - see here.

"..the aircraft diverted off the published heading.."  -  According to the approach plate if this was to be a problem (i.e. outside acceptable 'legal' tolerances) then the aircraft must have been deviated to the next MSA sector (R330° to R050° at MSA 5800').

If this was what occurred then from my interpretation this should automatically have defined this incident as 'serious', however from the ATSB record this does not appear to be the case:

Occurrence category: Incident

 
Therefore one has to question why the ATSB is investigating this incident?

Just surmising but perhaps there is a TASWAM element in this incident, see HERE. 

Just saying -


MTF...P2

[Peetwo]

To investigate or not to investigate? - that is the question.

Last Friday at 01:52 EST an incident was reported to the ATSB that apparently they will be investigating??  

Flight below lowest safe altitude involving Boeing 737, VH-XMO at Launceston Airport, Tasmania on 17 June 2016
 
Investigation number: AO-2016-061
Investigation status: Active
 

• Summary
  

Summary
The ATSB is investigating the flight below lowest safe altitude involving Boeing 737, registered VH-XMO at Launceston Airport, Tasmania on 17 June 2016.

While conducting the runway 32 ILS published missed approach procedure, the aircraft diverted off the published heading and flew below the lowest safe altitude.

As part of the investigation, the ATSB will interview the flight crew and gather additional information, including recorded data, as required.
 
General details

General details Date: 17 Jun 2016
 
Investigation status: Active
 
Time: 01:52 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Launceston Airport
 
Occurrence type: Flight below minimum altitude
 
State: Tasmania
 
Occurrence class: Operational
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Jun 2017 
 
Aircraft details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737-376
 
Aircraft registration: VH-XMO
 
Serial number: 23488
 
Operator: Express Freighters Australia
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Melbourne, Vic.
Destination: Launceston, Tas.
 
 
 


Last update 17 June 2016

However there is a couple of points with this incident that are more than passing strange??

To begin the statement that this was a flight below 'lower safe altitude' is misleading as every IFR qualified pilot knows the missed approach procedure for all IAPs is contained within the 25nm (or defined distance) Minimum Sector Altitude. Which for the sector that the 32 ILS missed approach heading of 313° is contained is 3,200 feet - see here.

"..the aircraft diverted off the published heading.."  -  According to the approach plate if this was to be a problem (i.e. outside acceptable 'legal' tolerances) then the aircraft must have been deviated to the next MSA sector (R330° to R050° at MSA 5800').

If this was what occurred then from my interpretation this should automatically have defined this incident as 'serious', however from the ATSB record this does not appear to be the case:

Occurrence category: Incident

 
Therefore one has to question why the ATSB is investigating this incident?

Just surmising but perhaps there is a TASWAM element in this incident, see HERE. 

Just saying -

Update 22/06/16: From that happy little chappy from Tassie, courtesy the Oz...

Low-level plane in ‘lucky escape’

• Matthew Denholm
  
• The Australian
  
• 12:00AM June 22, 2016
  

Only luck prevented tragedy when a Qantas-owned plane ­allegedly missed its approach at Launceston Airport and flew below the level needed to avoid colliding with high ground, ­aviation ­experts say.

The Australian Transport Safety Bureau is investigating the incident in which a Boeing 737-376, operated by Qantas ­subsidiary Express Freighters ­Australia, flew “below lowest safe altitude” just before 2am on Friday.

Veteran aviators Dick Smith and Byron Bailey told The Australian they believed the incident could easily have ended in tragedy and high­lighted the need for greater use of radar to guide planes at regional airports.

“The aircraft diverted off the published heading and flew below the lowest safe altitude,” the ATSB says. “… the ATSB will interview the flight crew and gather additional information, including recorded data.”

According to flight tracker website FlightAware.com, Friday morning’s flight left Melbourne at 12.55am. It appears the aircraft aborted a landing at Launceston, flying as low as 1100 feet at 215km/h at about 1.45am, before increasing power and speed to return to a higher altitude. Once back at 7300ft, at 1.51am, the aircraft was “div­erted”, probably by radar control in Melbourne, and climbed to 34,000ft before descending for what appears to be a second ­attempt a landing — this time successfully — at 2.38am.

Mr Bailey, a commercial pilot for 45 years who has trained Royal Australian Air Force ­pilots, said the pilot had been lucky not to crash into high ground. “It is very, very serious to deviate from your missed ­approach procedure because it is designed to get you to avoid any high terrain and get you to safe altitude,” he said. “So if you deviate from that, you are running a serious risk of crashing.”

At Launceston, as at many ­regional airports, during the day local air traffic tower controllers provide “procedural separation”, relying largely on radio and ­visual contact.

When the tower is closed, Melbourne radar centre provides assistance, but ­Mr ­Bailey said this was generally only down to about 6000ft.

“Everybody makes mistakes … and to suggest that below 6000ft the pilot should be totally on his own with no help is not a good look,” Mr Bailey said.

Airservices Australia said the aircraft was “under the control of Melbourne air traffic controllers at all times” and was shown on radar screens.

“Air traffic control noticed the deviation and ­issued a safety alert and instructions to the flight crew to resolve the situation,” a spokesman said.

However, Mr Smith said it ­appeared too little had changed since a “near miss” of two passenger jets at Launceston in 2008, when both missed their ­approaches in heavy fog after the control tower had closed.

The Civil Aviation Safety Authority and Airservices Australia are each reviewing elements of Tasmania’s airspace, following concerns about the state’s radar system and in light of rapid passenger growth.

Qantas last night suggested its crew had followed correct procedures after missing the ­approach to the runway in fog.

“The procedures for the missed approach were followed correctly,” a Qantas spokesman said. “At no point did any of the onboard warning systems on the aircraft trigger an alert to the crew. We are working with the ATSB to assist with the investigation.”

 

For those interested here is the Flight Aware link for the flight tracking (profile) of VH-XMO:

https://flightaware.com/live/flight/VHXM...T/tracklog

&..

https://flightaware.com/live/flight/VHXM.../YMML/YMLT
   

MTF...P2

[thorn bird]

Now lets see, around 15 years ago the airports were owned by the people for the people with no debt.

Then little Johnny was convinced there was a quid in it for the guvment so Murky and Beaker were tasked to flog them off, either to big banks or development sharks, not sure which one in Launnies case.

The buyers of course had to borrow lots of money from offshore to pay Johnnie thus creating a debt. Of course that artificial debt had to be serviced, so the industry and the people got raped with massive charges and squillions of dollars disappear each year into tax free havens around the world, leaving nothing for aviation infrastructure other than for building car parks or in the case of the development sharks, shopping centres.

So with no money left, and an industry on its knees from over regulation and unable to stump up any money Australia's aviation infrastructure degenerates to third world standards.

One can only wonder if so called privatisation had not occurred and some of those tax free squillions had been applied to aviation infrastructure how much safer it would be in Australia?

[Peetwo]

Is the search for IP pure folly?

The mad flurry of recent activity within the aviation accident investigation section of the ATSB and in the cover of a mind numbingly boring and seemingly endless election campaign, on my observation hasn't led to any great renaissance of Reason; or indeed the quality and relevance to the principles of ICAO Annex 13 of recently released major incident/accident reports:

World's best practice in CYA Aviation Accident Investigation -

K - If, you thought the Pel-Air epistle was an aberration; a one off, think again.  This latest abomination, following closely on the heels of the Mildura aberration speaks clearly of the total shambles ATSB has become under Dolan.

 

Bloody hell. I spend 4 weeks in Montreal and upon returning I find that Australian aviation has plummeted to even newer lows than one thought possible!

Mildura incident - what a crock of shit. That is an infantile and poorly investigated (or should I say poorly covered over) event. ATSB = shame shame shame.

VARA incident - crock of shit number 2. A childish watered down report aimed at the Year 3 students at my grandsons school. ATSB = shame shame shame.

Dolan my friend, you truly depart the ATsB on an all time low. You are 'beyond embarressing'. Never in my aviation career have I come across such an incompetent, out of ones depth buffoon. You will go down in history amongst the likes of Roger Chambers, John McCormack, Warren Truss and Terry Farkwitson. Absolute fool.

As for Hoody, well don't hold onto your Toga's awaiting miracles folks. The chiselled one will tow the party line and do whatever his superiors ask of him. Pumpkin Head runs this ship and nobody else matters. Hoody will no doubt have robust intentions, and the bloke is pretty smart and well skilled. Potentially the right man for the job. But when you look at who his Master is (and might be) - the likes of perm boy Chester or the great white elephant Albanese, you can see how we are doomed. Unless ICAO head down under and slide this nation the pineapple of a lifetime, I fear nothing will change.

TICK TOCK

However for one of the best summations of these incidents & accident reports, from our bollocks bureau that I have read, here is a quoted post from ozaub off the UP: 

The ATSB report isn’t getting the attention it deserves. Can I please draw invidious comparisons with attitudes to the loss of AirAsia QZ 8501 later in 2014. In both cases the crew mismanaged an upset with opposite control inputs.


The AirAsia A320 broke up in flight for many reasons, not least the language confusion and Captain telling FO to “Pull Down, Pull Down”. The airline was vilified and Indonesian aviation denigrated. However Indonesia’s report is timely and thorough.

For the ATR all we have is an interim report with many unanswered questions.

Opposite control inputs from ATR’s Captain and FO caused the left and right elevator control systems to uncouple from each other. It may not be common knowledge that many aircraft have separate control runs to each side of the elevator. The sides are connected by a clutch which in event of a jam disconnects and allows safe flight. In this incident independent and opposite movement of the left and right elevators via the captain’s and FO’s control columns respectively subjected the tail to asymmetric loads well beyond design requirements.

Subsequent ATR analysis found that the maximum load on the horizontal stabiliser exceeded design ultimate load by about 47 per cent, and the exceedance lasted about 0.125 second.

Somehow the ATR’s tailplane held together. Damage was so severe that the tail was visually twisted, yet nobody noticed. The plane continued in service and extent of damage was discovered almost by chance after a suspected bird strike. The aircraft was so severely damaged that ATR required complete replacement of both the vertical and horizontal tails.

Once again Australia kept its aviation reputation intact more by luck than competency. If you think that’s a harsh judgement read another recent ATSB report, into how two Boeing 737s nearly ran out of fuel and had no option but to land in fog with fuel and visibility below legal minima. Final report is at https://www.atsb.gov.au/media/577054...-100-final.pdf

  




MTF...P2

[Peetwo]

Q/ Is Hood already inflicted with AIOS?

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).





So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Following on from the recent series of posts on the RTMB & AA&MH370 threads - starting from HERE & HERE - the signs are becoming ominous that ATSB CC Greg Hood is already showing symptoms of being inflicted by AIOS -      

Here is some recent evidence pointing towards this possible diagnosis:

A timely, but fell warning.

Remember the old tale of the man who drowned at sea; having passed up three offers to save him; saying his god would save him.  When fetched up in his gods office he demanded to know why, after a lifetime of devotion he had been left to drown.  His god listened to the tirade, finished his tea and said: “Don’t know why you're complaining; I sent you the rowing boat, I sent you the yacht and I sent you the chopper; what else could I do?

The question of just how many more times Australia can ‘get lucky’ has similar connotations: the warning signals and the rescue offers just keep being ignored.  There exists a long, long list of bloody close calls, for airline operations, with hundreds of people at potential risk. If CASA, ASA and ATSB can’t or won’t heed the warnings then the bloody hat of blame will be firmly and squarely on the government head.  They have, collectively, allowed our safety network to become a legally risible, operationally shambolic, irresponsible, unaccountable system for wasting money which has not, nor will not repair a seriously deficient ‘administration’ and ‘over-sight’ for public safety airborne.

The FAA and other grown up nations are light years ahead and on the right course. Please, before someone gets seriously hurt; will the government listen to the truth provided by industry experts, not the platitudes, deceptions and fairy stories spun by those who must keep the myth alive, for their own protection.  FDS WAKE UP.

Nah, no steam required this time GD; but keep the boiler warm.

Toot toot.

And following that up today courtesy PlaneTalking...

Near miss, and attempt to shoot the messenger, add to doubts about ATSB performance
The ATSB is there to make flying safer in Australia, not to bury or avoid matters that may embarrass the airlines and their regulator and air traffic services provider
Ben Sandilands
A Jetstar A320 similar to the one involved in the Gold Coast incident

Perspective
If Australia had an ATSB air crash investigator with the resources and courage to promptly deal with pressing incidents that exposed the public to severe dangers, our skies would be much safer.

The most recent example is reported in this Sydney Morning Herald account of an arriving Jetstar A320 and a departing AirAsia X A330 coming within 152 metres of each other close to the Gold Coast airport on July 21.

That specified lack of separation could not be independently confirmed earlier today, but the triggering of traffic collision avoidance system or TCAS  resolution advisory warnings in both airliners with a combined count of more than 520 seats near a high profile Australian airport demands more than an ATSB estimate of an inquiry report being issued by July 2017.

The quotes from a Jetstar spokesman in the media report make the official notification from the ATSB look like part of its apparent policy of downplaying all incidents that could have ended in major loss of life.

Does the ATSB really expect that public interest to be served by not identifying, very early, whether the airliners were directed to fly towards each other in such a dangerous manner, or whether instructions were not followed by one of the aircraft?  Or indeed, if some additional unexpected factor contributed to the situation? These questions could and should be answered in an interim or preliminary report no later than 30 days after the occurrence of such an incident.

Delays in reports, and downplaying of their importance, have become characteristic of the ATSB for at least nine years, after it failed to pursue a situation where a REX turboprop was flown almost all the way from Wagga Wagga to Sydney on a single engine, with passengers onboard.

The Pel-Air crash of 2009 led to the issuing of a totally discredited and subsequently withdrawn report into the ditching near Norfolk Island of a corporate jet performing a medical flight. Despite scathing Senate Committee findings into that scandal, which involved evidence of the covering up of failed regulatory oversight by CASA, and a damning independent review of the ATSB by its Canadian counterpart, and a direction by Government to conduct a fresh inquiry, Pel-Air is still a crash without a final investigative report.

The ATSB attitude to the directions of government is something like waiting for hell to freeze over.

More recently the ATSB issued a Correcting the Record attack on a Sydney Morning Herald account of the failure of Virgin Australia to keep track of the safe operations of one of its turbo-prop ATRs. (Scroll down on the above link to find the offending entry.)
While the Sydney Morning Herald seems happy to hang the author of a totally fair and accurate report out to dry,  the ATSB response is unacceptable, and avoids the core issue in the article by Aubrey Martin. Like numerous posts in Plane Talking before, Mr Martin points out that an Australian registered turbo-prop, with 68 passenger seats, was allowed to fly 13 sectors over five days following damage to its tail, before Virgin Australia discovered that it was so badly bent it had to be grounded at Albury.

It was nothing but luck that stopped Virgin Australia killing dozens of passengers through a failure to ensure the safe operational conditions of part of its fleet. This failure of oversight by the carrier would have been reason to suspend the regional turbo-prop arm of the airline by CASA, and shouts for a need for urgent attention by the ATSB.

No such action has been taken, adding to legitimate concerns that Australia has second world standards when it comes to the public administration of air safety.

Seen from outside, the ATSB is under resourced. It is also more than three years since the ATSB began inquiring into the circumstances which caused a Qantas and a Virgin Australia 737 to land in dense fog at Mildura with very little remaining fuel reserves when both had originally intended to complete flights to Adelaide.

That set of incidents raised significant questions about the regulations concerning the fueling of domestic flights in this country. Yet despite a detailed interim report, the ATSB has yet to deal with this critical underlying issue in the Mildura fog emergency that overtook flights by Australia’s major domestic carriers and put hundreds of lives in peril.

"..The ATSB is there to make flying safer in Australia, not to bury or avoid matters that may embarrass the airlines and their regulator and air traffic services provider..."
P2 - Ben nails it with that last comment

Still holding judgement but the fact that Hoody in recent days, is persevering with the Beaker instigated 'correcting the record' web page and is now also actively using that page to defend (besides MH370) other dodgy high profile ATSB investigations, IMO is not a very positive sign that he intends to change the toxic culture of the ATSB...   


MTF...P2

[Gobbledock]

The new ATsB hey? None of this precious 'correct the record' bullshit took place when Stray looked after the place. Back then the ATsB wod investigate thoroughly, providing a factual and succinct report, and by their actions not leave themselves open to scrutiny. And if people did judge them or comment about them, well they would ignore it, life moves on, they couldn't have given a shit what the knockers had to say. And rightly so, they set the bar, they knew their shit, well. But under Beaker and now Hood, well dear oh dear, what a clusterf#ck.

[Peetwo]

In a nutshell Crocodile Chuck & George Glass -

Courtesy PT blog:

Crocodile Chuck
July 29, 2016 at 10:00 pm
ATSB in Australia: attempting to emulate the civil aviation safety record of Indonesia in the late '90s'?
[/url]
 

George Glass
July 31, 2016 at 6:16 pm
The ATSB has not reported on the Mildura incident because it knows the solution and is terrified by it. Why? Because it is in the pocket of the major carriers and will not,repeat will not, make a decision that imposes a financial burden on the industry.The solution is obvious to anybody in the industry. CAT 2/3 ILS or GBAS at all major airports within 10 years. Mandatory alternate required for all RPT operations where there is a single runway or crossing runways less than 3000 meters not capable of independent operations.Like everywhere else in the world.Until there is a recognition that Austalia's aviation infrastructure is totally inadequate expect more of these incidents as movement numbers grow and infrastructure is ignored by weak ,self-serving politicians and incompetent public servants.

 

1. 
   

Sam Jackson

[url=https://blogs.crikey.com.au/planetalking/2016/07/29/near-miss-attempt-shoot-messenger-add-doubts-atsb-performance/#comment-39864]July 31, 2016 at 6:35 pm

Nicely into a nutshell George.

 


MTF...P2

[Peetwo]

The new ATsB hey? None of this precious 'correct the record' bullshit took place when Stray looked after the place. Back then the ATsB wod investigate thoroughly, providing a factual and succinct report, and by their actions not leave themselves open to scrutiny. And if people did judge them or comment about them, well they would ignore it, life moves on, they couldn't have given a shit what the knockers had to say. And rightly so, they set the bar, they knew their shit, well. But under Beaker and now Hood, well dear oh dear, what a clusterf#ck.

He said she said

The 60 Minutes piece was interesting to watch, but mostly covered old ground. But I had two observations from the story;

1. Foley never looked at ease, not for one second. His body language mirrored that of a man who had just had a broomstick shoved up his ass sideways. And;

2. The lines were very very blurred as to who is running this effing investigation. The Aussies, Malays, or the god damn French?? One piece of wreckage goes to Australia directly, another piece goes to Malaysia and then to Australia. Another piece goes directly to the Frogs and after a year the Malayaians still don't have that piece in their possession and the Aussies can't answer why that is the case!

Seriously, who is sitting in the left hand seat?? What an embarrassment. The whole  investigation is in a state of flux, and the way it is being managed is a pathetic joke. And by default ICAO are a pissweak joke. Sitting idly by while nobody is sitting in the left hand seat.

The 60 Minutes reporter, although on the money for most of the grilling, is in my opinion not a formidable foe, in other words 'not a Richard Carlton' and Foley should have handled him without raising so much as a sweat. But Foley looked rattled, or was it pissed off, or was it both? Either way he didn't look or sound comfortable at all, in fact I thought he almost looked relieved when subtly casting doubt over the entire sordid mess. Or am I over-reading things? My impression was that there most definitely is a bigger game being played here by those in high places and the responses from Foley may indicate that those at the ATsB at his level and below might be getting somewhat sick and tired of the entire shambolic game and having to be the proverbial 'meat in the sandwich'?


TICK '60 Minutes' TOCK

To follow on from Gobbles line of ATSB criticism & observations, the following was Byron Bailey's quite understated spray in the Oz today:

Dear Dazza cc Wazza - L&Ks Byron Bailey

Via the Oz today:

MH370: enough of the spurious counter-theories

• Byron Bailey
  
• The Australian
  
• 12:00AM August 2, 2016
  

Fiction is easier to manipulate than fact. When the MH370 ­flaperon was found on a beach on Reunion, and shipped to France, amazingly the ATSB sent one of its experts to Airbus in Toulouse.

I did not know that the ATSB had any B777-qualified pilots or engineers so what was the purpose of the trip?

The real experts in Toulouse concluded the damage to the trailing edge of the flaperon was consistent with its being in a lowered position during an attempted ditching. It was not the hand of God that moved the lever to lower the flaps, but a human hand very familiar with the B777.

Shortly after, a report ­appeared in The Daily Telegraph, attributed to an ATSB spokesman, stating damage to the trailing edge of the flaperon was consistent with high- speed flight and therefore not the result of a ditching.

I immediately pointed out the absurdity of this claim, only to have the ATSB’s cheer squad spend an inordinate amount of ­effort to come up with alternate theories showing why I was wrong.

I have been supersonic thousands of times. Flying a B777, I have experienced M. 9 — 90 per cent of the speed of sound — during slight overspeed conditions. In certification the B777 is taken to more than M. 95.

But a B777 with an unresponsive pilot and engines dead from fuel exhaustion definitely would not be able to exceed — due alone to gravity in a dive — the huge transonic critical drag rise that ­occurs around M. 97, because of the huge drag of those big engines.

A flaperon in the streamlined position definitely would not suffer damage to its trailing edge and control surface flutter to rapidly destroy or detach the whole surface. In other words The Daily Telegraph report, if it was from the ATSB, was a figment of someone’s imagination.

I have been attacked in the media by aviation industry people with their own agendas, some billed as aviation experts though they have never flown an aircraft.

Those self-appointed experts have variously described as ­“malicious”, “scurrilous” and “hysterical rubbish” my ­attempts to make the ATSB ­recognise what it was feeding the public was just plain wrong. The ATSB, described by one of those experts as “the best of the best”, accused me of causing ­anguish to the MH370 families. Look in the mirror, ATSB and then transport minister Warren Truss; I am waiting for your apology.

In addition read & absorb from Sandy:

As many of us from the aviation industry have been saying for a number of years our 'independent' aviation oversight bodies leave much to be desired. It is truly disgraceful that the facts have been obscured for reasons we can only guess at. Perhaps questions of insurance liability, follow the money type concerns. Perhaps deference to the Malaysian's state owned airline and its reputation. Overtones of Malaysian politics may be involved.

Evidence appears to point to controlled flight, certainly from what we know this seems to be a more plausible scenario. What's known of the flight path never looked like a random, out of control meandering because auto pilots don't meander. But what do I know?

Having had a long career in General Aviation, I do know that the independent Commonwealth corporations, the Civil Aviation Safety Authority, the Australian Transport Safety Bureau and Air Services Australia have wasted millions of industry and taxpayer moneys in more ways than one. They are failed models of governance.

CASA has half killed General Aviation with an unworkable and ever changing rules, criminal and strict liability provisions plus huge fees for permissions. ASA huge expense and riddled with union controlled procedures which are dangerously behind the times.

Plenty of instances where good luck has narrowly averted tragic outcomes, Qantas and Virgin landing in fog at Mildura with little more than fumes in the tanks. Qantas Boeing south of Canberra below lowest safe altitude. Plenty more search the PAIN website.

Then the one directly involved spending umpteen millions in the search: ATSB, well used to covering and putting spin on issues that might point to the fallibility of CASA or ASA, must be greatly embarrassed by this revelation of material evidence in the MH 370 search which puts a big question mark over where the search has been conducted.

Dear Hoody might I suggest that now be a good time to pull, the obviously Dolan initiated, 'correcting the record' bollocks webpage and that you harden the duck up, steer clear of the running MSM commentary on investigations like MH370, the Mildura or ATR top-cover duck-ups. Simply put the ATSB is meant to be a fully independent (which includes government & other agencies), no fear nor favour Annex 13 principled AAI - but from where I'm standing that is simply a lie and deceitful deception of the public purse.

In the past words (not sure if he is still there?) of a Jetstar Perth based Senior Base pilot - "Toughen up Princesses!"


MTF..P2