[Kharon]

Quote:

"Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air."

Good point; and, in a normal world, it would be a legitimate topic for civilised peer discussion. But for Pel-Air at least I reckon it could stand a little expansion. For sake of argument lets 'assume' (we may, safely take a small risk) that the ATSB investigators were competent and they followed the well trodden path a 'bog-standard' accident investigation should take. The report even allowing for the 'theoretical' should have got us to within a bulls roar of the why, how and wherefore; it may have even provided some peripheral causal reasons which assisted in defining the desired end result – risk mitigation. There were several valid, not overly theoretical issues which did make it into the final report; RVSM, flight and fuel planning, lack of operational support, fatigue, lack of 20.11 training, etc, (don't ever forget, CP responsible for all) from which a reasonable operator could make adjustments to SOP, in an effort to mitigate the risk of reoccurrence. I don't have too many problems with the notion of 'theoretical', provided it can be translated, by the operator into practical fixes. So far the ATSB investigators are free and clear, reputation intact.

It's what happened next that got me cranky (just a bit): Sarcs at # 2653 has gone to some trouble to point out the direction a perfectly serviceable accident 'report' was being driven and IMO, in deference to the law, he has treated the 'aftermath' with kid gloves. For the thinking man, joining up the remaining dots to form the final picture is a piece of cake. The Senate inquiry surely got there.

It has been a long, slow difficult process since then: the Senators didn't waste too much time, their report was out in a timely manner; but since then, purgatory. Forsyth, then TSBC, then miniscule response, at the end we get (headline) "Pel-Air to be reinvestigated".

The academics and theory of 'how' to investigate an incident which happened, what ? five years and a bit ago have not changed and have had precious little to do with what transpired after the IIC report was 'edited' and produced. It's not Dr. John we need, but a judicial inquiry supported by the AFP, I'd even settle for the Senate committee as a DIP to manage yet 'another' inquiry (how many do we need). But FCOL someone with some juice do something – anything. Anything bar giving the true villains more time to clean up and hide the evidence which should rightfully hang the lot of them. The IOS has been very, very patient: thus far.

The comment below followed an article published by Australian Flying re the re Pel-Air MKII.

Quote:

Sceptical • 10 days ago

Head of Aviation Investigations at the time of the report? Ian Sangston.

Told of factual errors prior to release of the report? Ian Sangston.

Head of Aviation Investigations for the new report? Ian Sangston.

Conflict of interest?



Just about says it all. The background noise? Oh, that's the playroom clock; tick, tock, tick, tock.

[Peetwo]

In light of the recently released MH370 interim report (08 March '15) and the more than passing strange parallels to the PelAir debacle (or as I prefer to call it cover-up); I thought now was a good time to liven up this thread as indeed MH370 is severely lacking in investigative probity and also lacking government(s) transparency in process.

To begin the conversation let us refer to the Prune post (my post) to which kharon (above) mentions - Sarcs #post2653:

...However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...

From 3.5 Report preparation (November 2010 to March 2012) of TSBC report:

At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.

In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.

In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.

They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.

But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...

However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):

1.17 Organisational and management information

The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.

Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-

1.17 .1 Fuel Policy and Practice
• Inadequate fuel policy for Westwind operations.
• Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
• No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
• No alternate requirements specified for remote area and Remote Island operations.
• The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
• Criteria to obtain weather updates not specified in Operations Manual.
• Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
• No consideration of loss of pressurisation and an engine failure.

1.17 .2 Operational Control
• No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
• Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
• The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
• In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.
• Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.

1.17.3 Training
• Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
• Inadequate documentation of training programs.
• No formal training for international operations.
• Inadequate training records for pilot endorsement and progression.
• Inadequate records of remedial training.
• Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
• No mentoring program for First Officer to Command.
• Deficiencies in training records identified.

1.17 .4 Fatigue Management
• Over-reliance on FAID as the primary fatigue decision making tool.
• Inadequate adherence to FRMS policy and procedures.
• Excessive periods of 24/7 stand by.
• Lack of FRMS policy regarding fatigue management for multiple time zone changes.
• Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).

1.17 .5 Drug and Alcohol Management
• Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.

These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.  

Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture... Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5 (PDF 6032KB)...

The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..

18Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)

Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA? 

Well you may ask what has this all got to do with the investigative probity of the directly interested parties currently involved in the MH370 search & accident investigation?? To help explain the following is quoted from the beginning of Clive Irving's latest article on MH370:

Most airplane disasters are teachable moments that the aviation industry learns by. This is the way that flying – still by far the safest form of transportation per capita – becomes even safer. Yet in this disaster there is as yet not one piece of physical evidence to begin that process. There is however a trail of failures that expose serious lapses of responsibility across a wide range of airline and regulation practices.

& from Chapter 3.1 of ICAO Annex 13:

OBJECTIVE OF THE INVESTIGATION

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It
is not the purpose of this activity to apportion blame or liability.

 
  As signatories to ICAO both Malaysia & Australia are obliged to comply with the spirit & intent and the fundamental principles, of ICAO Article 26 & indeed Annex 13. History will eventually show whether the Malaysians have met their international obligations to ICAO - but the first signs are less than reassuring.  While in the case of PelAir & the ATSB there is no doubt that the State AAI did not meet its obligations to ICAO and therefore the greater world aviation industry and travelling public. 

Okay before we move on to Part 2 - in the search for investigative probity - I will leave you with an excellent blog opinion piece courtesy of Dan Parsons (Mid 2013): 

No Man is an Island

I’ve been a bit out of the loop over the past couple of months as I try to get a handle on my new job and the (almost overwhelming) responsibility that goes along with it. But I can’t ignore the action over at the Federal Senate’s Rural and Regional Affairs and Transport References Committee’s inquiry into Aviation Accident Investigations.

Before I comment, some disclaimers – I’m not going to comment on the particulars being discussed at the Senate hearings. While I worked with many of those involved, I never worked on anything associated with the accident event (before or after) but if I were to comment, it might look as though I have inside information, am bearing a grudge or just being an stirrer. I don’t, I’m not and maybe just a little .

I do, however, want to comment on the philosophy surrounding some of the issues at hand.

The particulars of the situation on which, I would like to comment are, basically, that an accident occurred and the resulting investigation focussed on the operating crew. In the 15th February hearing, two comments by Senator Fawcett struck me as warranting further examination. They were:

One thing the committee wants to put on the table upfront is we accept the contention by CASA that there were errors made on behalf of the pilot in command of the flight. There seems to have been some concern raised that this inquiry is all about exonerating an individual and shifting blame elsewhere. That is not the case. We accept the fact that in the view of some it was even a violation as opposed to error. (p. 1)

With the concept of a systems approach, whereby not only the operator and the pilot in command but also the regulator are key parts of the safety system… (p. 3)

For all the other problems we seem to be having in this scenario, we still seem to be stuck on the basics.

Part of a Complex System

Senator Fawcett’s second quote there and numerous others throughout the course of the hearing shows that he is quite familiar with the concept of a safety system but he, and I think a large part of the industry, can’t escape the concept of personal responsibility associated with criminal law.

The language of “exonerate” and “shift blame” suggests strongly that the old approach to investigations and safety improvement is still alive. We seem to have slid back into the days of pointing the finger at the front-line operator, stamping the label of “cause” upon them, punting them into touch, dusting our hands and declaring the world a safer place.

Okay, I’ll admit that this could be a harsh analysis of what is possibly a “throw-away” line but the language could indicate a deep-seated belief in the very concepts we are supposed to have left behind. I’m also not singling out Senator Fawcett. I think we all fight these traditional ideas, conditioned within us since an early age. How many of us still use the word “cause” despite its often misleading level of direct influence and independence?

Exonerate, Exshmonerate; Blame, Shame.

It’s a hard thing to let go of but, I think, we have to let go of the criminal view of personal responsibility when we are dealing with accidents in complex socio-technical systems, such as aviation. I’m just going to come out and say it:

No one, who participates in the aviation system, should ever go to jail, be fined or sanctioned as a criminal. Ever. Regardless of the error, violation, failing, mistake, slip, lapse, omission, commission, faux-pas, foul-up, whatever.

If we accept that aviation is indeed a system – a complex set of individuals, machines, procedures, tools, organisations – all working to achieve the objective of moving stuff from A to B – then no single part of that system can be singled out as having “failed”.

As a system there are, or should be, feedback loops. Sub-systems for checking and re-checking. There should be self-correction. If one part has failed, more parts have failed; in fact, the whole system has failed.

If you are going to blame one, you need to blame all. Jail one, jail all. Fine one, fine all.

Whoa Warden, Don’t Open that Door Yet

I am definitely not advocating some criminal reform agenda that would see society’s jails shut-down and personal responsibility disappear. I am arguing for a clear distinction between how we view undesirable events within the aviation endeavour and in society at large. I don’t think it is appropriate to look at the aviation industry as a sub-set of society and apply the same thinking.

The big differences between aviation and society are choice and intent. Pilots, ATC’ers, LAMEs, AROs and many others choose to be part of the aviation with the intent on achieving the industry’s objective of moving stuff from here to there safely.

Society on the other hand is, really, all encompassing. By definition, we don’t really have a choice to join. You could run off into the woods, build a log cabin and live as a hermit but you’d still be a part of society in the broadest sense and still, more importantly, be subject to various laws governing human relationships.

What to do with a broken part?

A while back the industry tried “no-blame” and it didn’t work. I think it was because the concept suggested there would be no ramifications, no consequences to behaviour which contributed to undesirable outcomes.

And this, of course, is untenable. If the system experiences an undesirable state or outcome, it should be able to correct its performance.

The response was to abandon “no-blame” as going too far but I think the problem was that the concept of blame actually ceases to have any meaning within a safety system approach. Much like one cannot meaningfully discuss events “before” the big bang, because time began at the big bang.

So What’s the Lesson?

The tiny lesson I’m trying to get at here is that we need to try harder to fully integrate the system approach into our thinking. It’s not so much that we can’t identify frontline operators as contributors to accidents but that there will (not might) be more to the story. Someone else, actually numerous people, will have contributed, in every case.

And in taking this approach, in identifying as many contributory factors as possible, the actions we take with respect to those people, tools, equipment, etc. will be and be perceived as appropriate. It will support actions like suspending a licence, grounding a fleet or withdrawing a certificate.

Without it, honing in on a frontline operator and booting them out of the system will never look justified regardless of how necessary it is.

MTF with Part 2 and Back to Reason...  
  

[Peetwo]

Wow what a mad week in Oz aviation safety circles, starting with Nick's CASR Part 145 disallowance motion actually getting up & then culminating last night with the 4 Corners story - Ditched . A week perhaps best summed up by Ben in his short article - Pel-Air shock, no trauma damages recourse for victims - yesterday (23 March '15):

...The person at the centre of tonight’s Four Corners report is nurse Karen Casey, who was on board the Pel-Air operated Westwind corporate jet performing an air ambulance flight when it was ditched in the sea near Norfolk Island in November 2009.

Ms Casey suffered serious injuries in the crash, during which she saved the life of her patient Bernie Currall, getting her out of the broken jet before it sank and then keeping her afloat until they and the other four persons aboard the flight were rescued by a Norfolk Island fishing boat.

There were only two and half life rafts  vests onboard for six people,  something our discredited air safety investigator the ATSB brushed aside in its much condemned but now withdrawn final report into the crash.

Ms Currall’s death earlier this month from unknown causes will be investigated by a coronial hearing.

A suppressed internal review by CASA disclosed by a Senate Committee inquiring into the mishandling of the accident investigation by the ATSB found that CASA had failed to properly oversight the operation, owned by REX, and that Pel-Air was in breach of dozens of safety regulations or requirements at the time of the crash.

The ATSB report into the crash was repudiated in its critical elements by a peer review by the Transportation Safety Board of Canada late last year, forcing the discredited Australian investigator to withdraw its report and start again, this time to carry out its full obligations to the truth in examining all contributing factors to the accident rather than simply blaming it all on the pilot.

The Four Corners report also revolves around the suffering Ms Casey has endured since the crash, including physical and psychological traumas that have taken away her livelihood and capacity to live a normal life.

But in 2013 the rights to damages for anything other than bodily injuries were stripped away for domestic air travellers by Australia falling into line with a Montreal Convention exclusion of personal or mental traumas for the survivors of international air crashes. (This wasn’t material for Ms Casey as her flight started in Samoa and WAS considered international. However it was the realisation that Australia’s actions had now put all domestic flyers in the same position as Ms Casey found herself that drove much of tonight’s Four Corners edition.)

“What happened to Karen Casey can happen to anyone, and in fact it can happen to more people now,” Senator Xenophon said.
“The law has been changed in this country to take away people’s rights to claim for psychiatric injury for PTSD which can be as debilitating and crippling as any physical injury.”

Last week Senator Xenophon successfully moved a Senate disallowance of Labor introduced legislation which degraded the standards of aircraft safety certifications in Australia for the apparent purpose of isolating the Licensed Aircraft Engineers Association in this country.

In a somewhat astonishing turn of events Labor senators supported the disallowance of the rule changes championed by former Labor Minister Anthony Albanese while they were strenuously defended unsuccessfully by Coalition Senators.

There are reports on that event and a fierce discussion on Plane Talking here, with a follow-up here.

Once the implications of Karen Casey’s story are more widely recognised, a similar repudiation of an Albanese initiative might just get up...

     
All of which makes a perfectly good setting for me to finally come back to Part II on the Reason model (causal chain) & the search for investigative probity.  IMO (& many expert opinions, including the TSBC) the original PelAir investigation sadly lacked any probity and was devoid of any real analysis & contributory factors of many of the red lettered organisational factors - that were bizarrely bullet pointed in the CASA CAIR 09/3 report (see above post under 1.17 Organisational and management information)??

To begin here is a link for 2 rather long comments that are rehashes of blog posts made by Kharon and myself on another Planetalking article from 20 January '15 - Pel-Air, party donations, and air safety. An inexplicable coincidence? {Warning: They are long but IMO put in context the whole PelAir debacle}

#P9 quote:

...The story of flight nurse Karen Casey will shortly come into the public domain and present an almost unbelievable, but sadly true picture to the world of the depraved practices eschewed by the legal, regulatory and accident investigation systems. The Senate inquiry clearly, unequivocally identified the collusion between the regulator (CASA) and the investigator (ATSB), the cynical disregard for ICAO Annexe 13 reflected in the 1700 registered differences; the open disdain for the condition imposed by an Act of parliament; but worst of all; denied the world the lessons to be learnt from the accident.

The failure of the life vests still remains on the shelf, gathering dust. You do realise that the failed life vests almost caused the deaths of all; had it not been for the unselfish actions of the Norfolk Islanders and a large dollop of luck all could have perished that night. Inconveniently they did not...

  
Then we had a posted comment from Gary Curral - one of the survivors & now sadly the widower of Bernie Curral, the patient on the last flight of VH-NGA -  which absolutely nails where this whole sorry, sordid, true story is at:

currall gary

Posted February 7, 2015 at 9:51 pm | Permalink

I am an enormous fan of the pprune bloggers and of Ben in particular so my aim is simply to project my experience – which may not agree with some of the posted info / opinion.

I, and I suspect others raised the issue of lifejackets with the ATSB during the investigation but from my perspective the issue was not with failure but with the lack of provision, or access or use – I do not know which aspect failed but I am convinced that each of the three lifejackets in use that night inflated as intended and continued to support the lucky three. I have no firm recollection or opinion on the issue of the battery operated light but I thought they operated as they should have.

For me the problem was that 6 people survived with only 3 lifejackets in use – this point was ignored by the ATSB despite my submission highlighting this and for me, was symptomatic of the way in which it appeared that the ATSB conducted their investigation – or at least reported the findings. Blindingly obvious problems – comprehensible even to a layman were ignored – training of pilots, RVSM, never mind the issues later revealed by the 4Corners program.

It was apparent even to me early in the proceedings that the investigation was going awry. I can only imagine the frustration of the regular pprune contributors who exhibit a far more detailed understanding of the issues. So while the problem of lifejackets is only a relatively minor one – unless you happen to find yourself paddling in shark infested waters 6 km off Norfolk Island – it has pointed the way to the ultimate question, posed repeatedly by the pprune contributors – WHY? Karen, through FOI, I think, has found the reason – the reason why the investigation was conducted Beyond Reason – by following the money trail.

The Senate committee -clearly experienced in getting to the bottom of air safety issues now needs to complete their work.
       

This bit...

"...was symptomatic of the way in which it appeared that the ATSB conducted their investigation – or at least reported the findings. Blindingly obvious problems – comprehensible even to a layman were ignored – training of pilots, RVSM, never mind the issues later revealed by the 4Corners program..."

...shows that even Gary - a layman by his own admission - gets the Reason model and its importance in establishing a causal chain - which includes organisational issues - that help to recognise and hopefully mitigate future safety risk issues.
Instead we have a situation where significant safety issues - one that was initially categorised as critical - have been unidentified, or left unaddressed, or with positive safety actions obfuscated for more than 5 years - see here: #Whodunnit & Why : Chapter 3.5 – In the eyes of the investigator & TOE - which IMO is simply unacceptable for a so called independent State AAI..

The following is a quote from Ben's Crikey insider article - Why are victims of Pel-Air crash not entitled to compensation? 

What about the Pel-Air crash anyhow? Where is it at? 

Where to start? A rotten-to-the-core safety regulator, the Civil Aviation Safety Authority, hid the truth about its own culpability in setting up the administrative vacuum in which Pel-Air was able to break dozens of rules or obligations; the safety investigator the Australian Transport Safety Bureau tried to pin it all on the pilot;  and the ATSB’s Canadian peers told them they had screwed up, also revealing in passing that the final report was preceded by turmoil within the ATSB as it wrestled with its direction in the final months before it was released.

That ATSB report is now being redone, unfortunately by the ATSB, possibly adding to the damage this episode has done to Australia’s air safety reputation, and to the lives of all onboard the Pel-Air flight, including Bernie Currall, the patient, who died earlier this month.

Spot on Ben..

MTF...you bet! P2

[P7_TOM]

Of wabbits, wascals and weports, Australian style.

The Karen Casey story from the ABC was not too bad an effort at all. It certainly is one for the 'punters', without who's good will and support, Nick Xenophon could not continue with his Senate colleagues to do as much as they have done to assist the neglected aviation industry. We (collective) send a vote of thanks to the 4C team and the lawyers who probably allowed enough latitude to at least get the essence, if not the detail of the story to the public. Well done ABC, 4C, Kerry O'Brien and Geoff Thompson, thank you.

For the purists, well there was precious little in the way of detail, NX managed to parallel the truly dreadful ATSB management behaviour after Per-Air with MH 370. PAIN has long held the belief that despite the spin, window dressing and Merde'k manipulations, that Beaker and his invented 'beyond all reason' ATSB rational would ultimately prove an embarrassment.
Any comprehensive analysis and chronology of the Pel-Air investigation comprehensively defines a twisted, dual pathway to perdition. The same disrespect for the tenets of the ICAO annexes relating not only to reporting, but the authority of the IIC and the 'probity' of the investigation is clearly visible. Malaysia and Australia both, guilty of masquerading as 'honest' ICAO citizens, without ever letting the truth stand in the way of a required outcome.

Some, but not all of the disturbances to the TSI Act and ICAO principals have been examined; those outrages have, thus far been ignored and trivialised by the government, under advisement from the 'department'. PAIN believes this advice has been proven to misrepresent the governments position and to camouflage the plain fact that CASA is not only out of control, disassociated from industry and operationally dysfunctional, but morally bankrupt.

Somewhere on the Aunty Pru web site, the PAIN submissions to Senate have been posted, these now form the base for an independent PAIN report which will be published just before the current ATSB investigation of the ATSB investigation is published. The delay is due to monitoring the ATSB investigation as is slowly, reluctantly progresses. Remember, the ATSB is only investigating the accident 'event', not the unholy aftermath. Due to the narrow 'scope' and very limited terms of reference, not to mention a distinct lack of managerial enthusiasm, some of the items the ATSB will not be revisiting are to be examined on their behalf; such as:-

The time line, chronology if you like. For example on or about Feb 12, 2010 something 'changed', a paradigm shift, which leads to many serious questions, as yet, unanswered.

The tricky, deviated CAIR 03/09 report. Standing alone the 03/09 report is an anathema, with the moody background and blatant connivance exposed, it has the potential to become a living breathing nightmare.

The Chambers driven, Hood sanctioned suspension of the James license leads to some very dark corners in the CASA firmament. In combination with the infamous Chambers report it forms an ultimate insult to the integrity of Australian aviation management. The Chambers report, cynically drafted, happily plagiarised, primarily to justify an abhorrent act, shaft enemies, denigrate good honest reporting, gain kudos and curry favour. Despite that report being used by the Senate as a handy stick to beat the CASA donkey, it is now slowly emerging from the twisted wreckage and being recognised for what it truly is.

There is much the ATSB will obfuscate, slide around and sweep under their carpet; it is after all said and done, their very own investigation of themselves. The comparison between the ATSB/CASA assisted 'report' and the independent PAIN analysis will be 'interesting'.

But, I digress; let us hope that the 4C report influences some hearts, focuses some minds and wakes the bamboozled miniscule out of his departmentally induced coma; before Bill Shorten figures it all out, check mates Albo and turns the whole sorry mess into a hag ridden nightmare for the struggling Abbott team. The Minister and his minions cannot claim we didn't warn them that the roof was about to cave in.

P7_TOM.

[Kharon]

Pandora's box, cleverly locked.  

The decision for PAIN to protest the Ministerial decision allowing the ATSB to re examine the Pel Air ditching was not made lightly. The associates unanimously agreed that the prospect of litigation being heard and ruled on, before the new ‘investigation’ even began in earnest and a definitive ’cause’ established which could impinge of the courts decision was risible. The decision handed down may only rely (in part) when deciding liability on the original grossly flawed ATSB report. No one wants to be liable, certainly not CASA, not the company, not the pilots, not the government; so who then? One of the associates summed up the  problems and concerns very succinctly:-

..If I was a shareholder of Rex then I would be asking why Rex was not suing CASA for CASA’s deficiencies which contributed to the crash. Given 3rd parties have cited CASA deficiencies and contribution to the crash, why on earth should the company of which I own a share carry all the financial loss?

..And if I was a shareholder of the Rex underwriters, I would be asking exactly the same question. Why should my company pay all the damages when it was insuring only one of the responsible parties.

To whom will the insurance companies turn for recompense? Perhaps the manufacturers of the life support equipment? It could be argued that until the life raft vanished (sunk) and the life vests partially failed, Karen, apart from being ‘shocked’, was hale, healthy and fit enough to support her patient for 90 long, cold minutes in open sea.  Fit enough to physically support and mentally comfort the distressed patient, her physical injuries and mental distress all stem from that heroic effort.

..GEOFF THOMPSON: Lawyers representing Pel-Air and its insurers say there is no connection. They argue that Karen’s PTSD stems from her experience of the crash itself and not from her physical suffering.

Other items, not mentioned, but of interest are the loss of the life raft, (who’s to blame) and the failure of the life vests (who’s to blame) and the associated equipment failure (lights and whistles). Who approved the 20.11 procedures (training, evacuation and ditching procedures) ? who was responsible for that approval? and who was the ultimately responsible CP, who simply accepted that “all” was well.

These are just a sample of the questions raised within the association; all demand answers, many would, (or should) have an affect the court decision and the outflow from that ruling.

The notion that the ATSB can ‘re investigate’ the accident after a hearing and that they can be totally relied on to provide ‘investigative probity’ and an acceptable report, after it has been clearly demonstrated that the first report was fatally flawed, is a non sense.

.KERRY O’BRIEN: So there’s the letter of the law and there’s conscience. Somewhere between the two is Karen Casey.

Judgement in her case for compensation will be delivered sometime this year. Pel-Air declined to be interviewed or answer written questions, telling Four Corners that it is “legally bound not to discuss any aspect of the incident pending the final resolution of the court case.”

FWIW – the submission to the Senate is – HERE -. Spam and virus free from Aunty Pru.

Selah.

[Peetwo]

{On behalf of the Sheikh I moved his partly duplicated post (from here) to this thread as it is IMO extremely relevant to the investigative probity of the current (Beakerised) mob heading up the ATSB..P2}

Ladies and gentleman,

Here we go again with Pel-Air! The ATSB new IIC has today contacted Karen Casey advising that the lifejackets from the accident were now in their hands in Canberra. After 5 1/2 years you have to wonder why on earth it took so long to recover such critical evidence. Apparently the Norfolk Island police had stored in a back room storage for 5 1/2 years!!! What's even more concerning is that there was an inference made that Karen hadn't inflated her right chamber. Serious questions need to be asked to the ATSB;

1. Why didn't the ATSB ask for the lifejackets when they were there on site the day after the accident?
2. Why didn't the ATSB check the time life and expiry dates of the lifejackets when they were there on Norfolk Island?
3. Why did the Norlok police not offer the lifejackets as evidence to ATSB?
4. How would the ATSB be able to determine which jacket Karen was wearing?
5. Has anyone been able to check the serial numbers of the lifejackets and compare them with the Pel-Air engineering data?
6. Considering the lights on the jackets were questionable why didn't the ATSB immediately inquire into this?

The list goes on. Karen was floating in 3 metre seas in the dark with virtually zero visibility for one and half hours. That itself gives good reason as to why she would have tried every attempt to inflate her life jacket chambers whilst keeping Bernie, her patient, alive. Bernie had no life jacket. Also Dominic James tried to assist her at least once to inflate the other chamber, whilst he had no lifejacket himself.

This whole thing STINKS and the ATSB are up to more antics here. Now preying on the victims! Pathetic. Im going in hard for all.

Sheikh Yer Booti!

Ps P2: Please consider the vomitus weasel words from Dolan in the recent joint presser from the ATSB & CASA on the MoU :

Mr Dolan said, ‘the MOU spells out how the two agencies will cooperate in the interests of improving aviation safety. We are working together - with the ATSB identifying safety issues through its investigations and findings, and CASA and the industry responding to those issues, as appropriate - to promote high standards of aviation safety.’

  
Then consider the veracity of the Dolan statement in light of the Sheikh's very disturbing post...FFS  

[Kharon]

Disingenuous? ATSB?, Oh you bet.

As forecast by Aunty Pru, Beaker leads the way.  The ATSB cannot be trusted to reinvestigate the Pel-Air ditching let alone the manipulation of the manipulated final report.  This is the crowd 'helping' the Malaysian government.  The question; just how are they helping, begs answer. 

The Sheik's disturbing post only gives an inkling of the duplicitous nature of the ATSB management ethos, which is fully supported by the government DoIT and by extension, the Minister.  Manning, the new boy is conspicuous by his absence; meanwhile the ubiquitous Uriah Heep continues his on his merry way, unashamed by the Pel-Air report, the Senate Inquiry or the TSBC peer review.  The thing that  really gets me cranky is this benighted industry will, passively sit back and let 'em get away with it: MILDURA; ATR 1; ATR 2; REX 1,  all outstanding examples of how to PC air safety into a 'DIY', in house side line for Safety Management Systems.  

You wait for the company concerned to fix it; wait for CASA to decide if there is a juicy prosecution available; wait until the airline has covered it's arse: then, trot out a fluffy report which says, what happened, what has been done and that all parties are thrilled to bits.  Who needs the ATSB then? no one is the answer, they can just hire a technical writer to mop up, save a fortune and play golf whenever they like (tax payers expense of course) The peer organisations such as NTSB and TSBC must be watching closely; for they too, like a game of golf.  

Here are some of the concerns which PAIN registered with the Senate during the Pel-Air inquiry; still valid, still virginal and still, as yet, unanswered.  We just hope they have done their homework as well as the PAIN research crew have. The questions will be answered then by Golly..   Supplementary submission – HERE – from the AP library.  

Ok, ok, -STEAM OFF.  Well, honestly; etc. etc.   

Toot toot..

[Gobbledock]

What we need is the FAA to take a very close look at the Australian shenanigans, and to do this parallel with but not linked to ICAO who should also take a look. They ought to as the iceberg is well and truly exposed -  the myriad of QF issues since 2008, Lockhart, Pel Air, REX vs a coal loader, a bent VA ATR that simply defies belief that it never speared in, and the list goes on. The muppets at CAsA like to talk about 'red flags'. Well there are so many red flags covering the feckin Australian landscape it looks like the crash scene from the Germanwings crash. ICAO and the FAA must be concerned, surely? And if they aren't then we are all doomed. At this point in time it will take a downgrade or a major smoking hole to jolt the bureaucracies out of there coma like condition. But it doesn't have to be that way. We have some very capable people concerned enough to bring things to light. People like Nick and company, Forsythe, Boyd. Then we have potential players such as Skidmore and Manning. All the above mentioned folk are at least mentally stable and don't exhibit sociopathic traits so that is a positive thing. The downside is that the forrests timber is full of ferocious white ants who will not stop until they either run out of wood or they are dealt with swiftly and brutally by an exterminator with size 14 boots.

Unfortunately Australia's run of sheer luck when it comes to not yet having a 300 seat smoking hole will NOT last forever. The Miniscule, as with the Miniscules before him are running a high stakes poker game. Eventually the house will collect.

Below is a worthy episode of Twilight Zone worth watching. Reminds me of the game that CAsA, ATsB and Pumpkin Head are playing;

Tick tock Miniscule tick tock. Dealers call.......

[Peetwo]

Excellent post Gobbles dealers call indeed...

They ought to as the iceberg is well and truly exposed -  the myriad of QF issues since 2008, Lockhart, Pel Air, REX vs a coal loader, a bent VA ATR that simply defies belief that it never speared in, and the list goes on. The muppets at CAsA like to talk about 'red flags'. Well there are so many red flags covering the feckin Australian landscape it looks like the crash scene from the Germanwings crash. ICAO and the FAA must be concerned, surely?

Well you'd think so wouldn't you?? Not so much the smaller flying tin incidents but the Mildura fog incident and a couple of those recent ATC LOSA events you would of thought may have grabbed their attention?? Hmm...maybe there is some sort of filtering going on between the time the original incident report is received & when the official ATSB incident report is forwarded to ICAO for input into the iSTAR database?? Who knows but it is certainly passing strange and we all know that the powers to be have been caught fudging the books before...  
 Wikileaks: Australia nearly lost its air safety rating 
2004 AUDIT REPORT OF THE AUSTRALIAN TRANSPORT SAFETY BUREAU (ATSB)
{Ref: In particular see Appendix 5-1} 

Oh well at least we seem to have made some progress to aviation safety reform with the recent release of the 2015 ATSB/CASA MoU - see here or here.

However until such time as someone acknowledges that the muppet Dolan has to go, we will continue to get absolute bullshit statements like this in the joint ATSB/CASA MoU presser...

"...Mr Dolan said, ‘the MOU spells out how the two agencies will cooperate in the interests of improving aviation safety. We are working together - with the ATSB identifying safety issues through its investigations and findings, and CASA and the industry responding to those issues, as appropriate - to promote high standards of aviation safety.’ ..." 


Those words should - coming from the head of the ATSB - provide reassurance that maybe the worm has turned & after the PelAir cover-up debacle, the ATSB is on the road to recovering some of its former reputation & effectiveness as the Australian air safety watchdog. Unfortunately coming from Dolan - who has absolutely no credibility whatsoever and could not lie straight in bed - they are empty words coupled with much recent evidence (besides PelAir) to the contrary.

To get an idea of the extent of the problem lets look at a couple of recent examples, starting with the progress of the Mildura fog incident investigation. {NB: Except that it was over land the parallels in this incident to the VH-NGA ditching are quite striking}

Quote from the tail end of ATSB investigation AO-2013-100 prelim report:

Continuing investigation


The investigation is continuing and will examine the:

• provision of information to flight crews from ATS

• ATS policies and procedures affecting the flights

• provision by the operators of information to the respective flight crews

• the basis for the sequencing of the aircraft landings at Mildura

• Bureau of Meteorology meteorological services and products as they applied to these flights

• accuracy of aviation meteorological products in Australia.

The final report is anticipated for release to the public by June 2014. Should any critical safety issues emerge during the intervening period, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations and publish them as required.

Well apparently the fact that a combination of systemic safety issues placed two HCRPT Jets in a severely compromised position - where they very nearly ran out of fuel and had to land in conditions below the published instrument landing minima - is not significant enough for the ATSB to publish any safety recommendations or even safety issues/actions. 

But hang on maybe there was something in the 19 December 2013 interim factual report??

Safety Action

As a result of its developing understanding of the occurrence, the Australian Transport Safety Bureau (ATSB) has commenced the following safety action.

Safety forum regarding the provision of operational information

The ATSB is planning to convene a safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally. This forum is planned to include representatives from the Civil Aviation Safety Authority (CASA), Airservices Australia (Airservices), the Bureau of Meteorology (BoM), the operators of VH-YIR and VH-VYK, and other relevant parties.

The aim of the safety forum is to:

• apprise the participants of the circumstances of this occurrence as understood to date

• identify and analyse any gaps in understanding of the responsibilities and processes for the dissemination of operational information to flight crew, when on the ground and in flight

• discuss/examine options for improving the reliability of the dissemination of operational information to flight crew.

It is anticipated that this forum will take place early in calendar year 2014. The results of the forum will be included in the ATSB’s ongoing scoping of its investigation and, where relevant, included in the final investigation report.

Reliability of aviation weather forecasts

As a result of this and other occurrences involving observed but not forecast weather, the ATSB has commenced research investigation AR-2013-200 Reliability of aviation weather forecasts. This investigation will analyse BoM data across Australian airports, with a focus on those supporting regular public transport operations, and is subject to the availability of long-term data holdings of aviation forecasts and observations.

Analyses will be performed across time, comparing forecast and observed conditions as they affected aircraft arrivals at particular airports. The focus of this examination is limited to observed conditions below specified aviation minima, or other conditions that may result in aircraft exceeding safe limits of operation.

This research investigation is expected to be completed by mid-2014. When complete, the investigation report will be available on the ATSB’s website at www.atsb.gov.au.

Ah yes the infamous "love-in" - so do we get any feedback on how the closed door forum went and what safety actions are proposed by the DIPs?

Updated: 5 June 2014


As forecast in its interim factual report of 19 December 2013, the ATSB convened a safety forum on 31 March 2014 involving a number of industry participants. The forum identified a number of issues, most of which are pertinent to this occurrence and more widely across the aviation industry. These included:

• differing levels of expectation in relation to the provision of amended meteorological products
  
• inconsistencies in standard aviation reference documentation in relation to the use of meteorological products
  
• differing levels of understanding and awareness of the availability of meteorological products, including limitations relating to automated weather broadcast systems
  
• the effect of international obligations and restrictions on the provision to flight crews of updated weather information
  
• limitations associated with the staged introduction of new technologies
  
• the need for a coordinated education program to update and deconstruct many long held beliefs and misconceptions within the aviation industry.
  
  

The investigation is continuing, with the majority of the initial evidence collection complete. In addition to its analysis of this initial evidence, the ATSB is continuing to work with sections of the aviation industry to enhance its understanding of the issues that were identified at the safety forum and identify any safety issues. This additional work, and any implications for aviation safety, will be included the ATSB’s final investigation report, which is now expected to be released to the public in November 2014.

Should any significant safety issues emerge during the intervening period, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations and publish them as required.

  
Okay so presumably the DIPs have commenced/proposed safety action so why is this not published or at least acknowledged?? And what has happened to the final report - don't tell me we have got another bloody PelAir??

Hang on here was an update courtesy of Hoody :

Then..

Updated: 10 November 2014

Completion of the draft investigation report has been delayed due to further evidence collection. It is now anticipated that the draft report will be released to directly involved parties (DIP) for comment in December 2014. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in March 2015.

Okay but wait there's more.. zzzzzzz:

Updated: 25 March 2015


The investigation completion date has been extended to allow for the examination and analysis of increasingly complex data and information. Additional resources have been allocated to the investigation team, in part, to examine a number of subsequent occurrences that have potentially similar factors with the Mildura occurrence.
Following the safety forum that was convened with industry last year, the ATSB continues to work closely with relevant sections of the aviation industry to address the issues that were identified at the forum and to promote safety action.
ATSB anticipates the final report will be released to the public in August 2015.

 
Oh (part in bold) I feel so much better for knowing that...FFS

MTF...P2

[thorn bird]

Jeez, P2, wouldn't it just be easier to let CAsA announce the pilot, either one or both dunnit, let wodger wabbit loose to work out administrative embuggerence, problem solved.
Oh sorry, inconvenient truth....there's a fairly supportive union behind the pilots aint there. Pity, be much easier that way, CAsA gets another scalp, Wodger gets his rocks off, save heaps of money.
Punters have long forgotten the incident and probably didn't care that much anyway because nobody ended up in a smoking hole.

[Peetwo]

Jeez, P2, wouldn't it just be easier to let CAsA announce the pilot, either one or both dunnit, let wodger wabbit  loose to work out administrative embuggerence, problem solved.
Oh sorry, inconvenient truth....there's a fairly supportive union behind the pilots aint there. Pity, be much easier that way, CAsA gets another scalp, Wodger gets his rocks off, save heaps of money.
Punters have long forgotten the incident and probably didn't care that much anyway because nobody ended up in a smoking hole.

Naughty Thorny to suggest such a thing could be blamed on the Skygods is shear blasphemy...   As an example with the UP Mildura fog duck-up thread see what happened to "K" after he posted this thought provoking piece - #280

...To sort out the 'Mildura' issues is going to be a big job. Clearly there are major corporate, crew, meteorological and on the fringes, legislative issues. Although I feel the 'regs' are blameless this time – the Australian fuel policy is useful, flexible and with a little common sense tweaking works fine, for grown ups capable of taking responsibility and allowed to make decisions, although it does expect that the crews can look at the presented forecast, make an informed decision and order an extra few, discretionary drops of fuel – (to be sure, to be sure). Or to bugger off somewhere else before things get too 'tight'.

Once again, there are deep issues involved, BoM practice, methodology and policy. Corporate pressures, operational policy, pilot training, human factors; etc. in fact, all the parts of a crash puzzle except without body parts melded with aircraft parts, for the third time now. (Fuel x 3 + Weather x 3).

Mildura is a serious, but subtle event. Now, can our compromised ATSB sort it out before centuries end?. Will the report have any value?. Is the political will, savvy and interest required to make the recommendations stick there?. Or will we just end up with the 'company has amended their policy' etc; or, two crews re sitting their ATPL Met exams a' la the Chambers system. Or perhaps, McComic will just blame the whole shemozzle on the ills of society, con yet another minister and leave the spin to those who know how best to do it. One thing the Senate has achieved though, there will no disgustingly obvious cover up; not this time.

I don't know which concerns me the most: but close to the top of the list must be that two, not one, but two separate airlines finished up, operationally compromised, landing in less than ideal conditions, at Mildura. A foggy day should end with multiple complaints to management due to delays, missed connections, changes to crew rosters and a higher fuel bill; not with a full on declared fuel emergency and Brace, brace, brace.

Winter fog in Australia is not 'unusual', there are a few options available; delay, divert, hold and divert. All corporately unpalatable and operationally problematic; but, rock solid safe. A skipper has all of those options available, fully supported by law. The 'company' policy does not signify.

One concern, worthy of some consideration is 'crew attitude' and whether the ATSB has the balls to tackle the subliminal pressures to 'be on schedule', minimise fuel uplift and yet manage to not compromise or embarrass the company. Why did both crews not throw on 'gas for Mum'?. The little alarm bells of experienced crew, going south, early morning, in winter with the ambient weather conditions should ring, and a discreet, prudent 30 or even a big fat 60 minutes could be 'smuggled' inboard without adverse operational comment. Did two, not one, well fed, rested crews not 'see' the possibility of fog and take appropriate measures, I doubt it.. "One is unfortunate, two begins to look like carelessness". I believe we are allowed to ask why, just in case the nanny state or corporate dogma has managed to brainwash or bully a more politically correct generation of pilots, without denigrating the crews involved.

Three incidents, no bodies. Lucky country ? you bet.

Brace, brace, brace.

Where's me old tin hat.

Hmm...passing strange that "K" agreed on anything that came off Tinbindildo's keyboard/apple device...

Next moving onto to another bizarre & outstanding ATSB (supposedly pc'ed) investigation, that of the bent tail ATR VH-FVR: AO-2014-032  
This serious incident only came to our attention when VH-FVR was strangely grounded indefinitely after the Captain reported a possible bird-strike incident on approach to Albury. We then discovered that the identified structural damage to the ATR actually occurred 5 days earlier on CB to SY sector. And that is where the details of the ongoing investigation started to become strange...   
Planetalking articles - Virgin Australia’s leg breaker ATR now ATSB tail breaker plus...

 

Was it a bird, or a stuff up? The Virgin ATR questions
Ben Sandilands | Apr 23, 2014 1:12PM |

Whatever it was that the ATR hit, it was definitely too damaged to continue to operate in the state in which it came to rest in Albury


Julie Andrews in Sound of Music, or the ATSB in Albury? PR photo 20th Century Fox

There are unresolved issues about the Virgin Australia ATR turbo-prop currently but not always hidden from view at Albury Airport following the discovery of significant damage to its airframe after it landed there on 25 February.

The aircraft was also involved in a serious turbulence incidence on the a flight between Canberra and Sydney on 20 February, and in an earlier post we have described how the ATSB linked that incident to the later Albury incident in a manner which no doubt by pure coincidence rendered it invisible to public scrutiny.

Among the questions awaiting answers is the extent to which, if at all, the public was exposed to risk between 20-25 February  by the aircraft continuing in service.

It is important to ask the question without prejudice. The ATSB could be completely mistaken in linking the two incidents and to have done so without any substantive reason whatsoever.

Virgin Australia had the ATR inspected after the turbulence incidence by a contractor, who may well have correctly concluded that the aircraft was fit to fly.

The pilot who thought he hit a bird on approach to Albury and made an external investigation of the turbo-prop to discovered what could be one of the more ruinous bird strikes in the history of such incidents in Australia could have been correct in his suspicions.

But whatever it was that the ATR hit,  it was definitely too damaged to continue to operate in the state in which it came to rest in Albury, where according to Virgin Australia:
 An ATR-72 is currently in Albury awaiting repairs, the aircraft is currently under ATSB control and the repairs will commence once the ATSB’s investigation is complete.

Virgin Australia also said “Virgin Australia pilots conduct a pre-flight inspection of their aircraft prior to every flight”. This tells us that whatever was bent on inspection in Albury after landing wasn’t bent before take off in Sydney more than an hour earlier and infers that either a prior condition suddenly manifested itself in the airframe or was caused by hitting what must have been a very large bird with its T-tail.

Finding out the truth is obviously a matter of considerable importance, and there is a sequence of events from the actions the pilots took on 20 February to respond to turbulence through to the post turbulence inspection and on to whatever event caused the airframe to deform on 25 February that all need to be fully understood.

The most important matter of all might be whether the airliner flew while in an unsafe condition between 20-25 February, and if it did, what steps need to be taken to prevent this happening again.

But the integrity of the post turbulence inspection process is obviously also critical to the above.
Answers to these questions are needed.

In a transparent and accountable air safety administrative process these issues would be explored NTSB style, at public hearings.  Documents would be produced and examined. Responsible people would publicly account for their actions. In Australia such matters are settled out of sight through a process of negotiation when it comes to the wording of the final report between the safety authorities and the commercial and professional parties to an inquiry, leading to an agreed final document, although the ATSB does have the power to publish its findings over the objections of other parties.

For the time being Virgin Australia isn’t proceeding with its originally intended expansion of its regional arm, which was Skywest Airlines of WA , which it purchased from Singaporean shareholders last year.

Then - Virgin Australia flew 13 passenger flights in broken turbo-prop - which Ben began with this question...

"...Where on earth is CASA as well as Virgin Australia and the Minister for Aviation in relation to the shocking update by the ATSB in the case of a damaged 68 passenger ATR72 turbo-prop that was allowed to fly 13 times in scheduled service after a turbulence event on a Sydney-Canberra flight in February?..."

And what has happened since & what have we learnt from this incident(s)? Well according to the publicly available records off the ATSB website....um..err..not much??

TBC/- Definitely MTF with this ATSB investigation (& others) P2..

Ps You will all be pleased to hear that VH-FVR's broken tail has been fixed and is reportedly back flying the line??

 

[Gobbledock]

I'm sure the tail is now firmly straightened out, no kink in the aircrafts shape, I'm sure those who are used to flying her will notice nothing different at all!!

As for 'K' agreeing with Tid-bin-dildo, that is indeed a rare occurrence! However I have noticed that once again Tid-bin-dildo and Stailwheel have been flexing their tiny winkies and threatening to sideline one poor poster that dare to speak his mind on the tropic air thread. Naughty naughty, on UP one must remain politically correct at all times and not speak the truth, not be playful, not talk about any important safety topic, and at all times one must kiss and caress the Mods pimply white asses! Hang on, I just described Lookyloo????

Calling 'Pilot 58', come over and play on Auntypru.

[Kharon]

P2 – "Hmm...passing strange that "K" agreed on anything that came off Tinbindildo's keyboard/apple device"..

GD –"As for 'K' agreeing with Tid-bin-dildo, that is indeed a rare occurrence!"...... .......

This is correct; it's so very rarely that the pedantic, narrow backed, miserable, misogynistic bugger ever has anything of value to say, I also agreed with his off-sider once.  Just an example of how to play the ball, not the man – why?  Well, weaving their points against in, to support your argument, making it stronger, is fun; along with the added bonus that it annoys the crap out of 'em, makes the temptation irresistible; mea culpa......... Now to business.  I guess we must start with two questions: what the hell is Manning playing at? and, what on earth are the ATSB 'honest vineyard toilers' thinking?

It is becoming farcical to the point where, as said previously, why don't we just hire a technical writer to draft half a dozen pro-forma reports, which can at least be published on time.  When you start deconstructing the pitiful efforts of the ATSB accident reports, that's what they boil down to.  A little bit of ATSB fluffy technical analysis, the summary written by a CASA word weasel, couple of pictures and, job done.   Said it all before – HERE - 

This business at Mildura could have ended in tears, except the gods were benign and the weather was willing to cooperate.  The message was clear- ignore this warning at your own peril.  The NTSB or TSBC would by now have their interim reports and more than likely at least three SR out, for discussion with the agencies concerned.  We get a teddy bears picnic, some happy clappy, tent revival with tambourines at the corporate love in.  The whole thing buried under a pile of used soft white paper and wrapped in time.  This ensures that no one will want to pick up the mess and it will, conveniently, with the passage of time, be forgotten.

The BoM features in too many 'incidents' and need to be brought into the 'accountability' stakes.

Corporate attitudes need retro-modification to realise that the PIC, not the bloody bean counters command the aircraft.  If the BC want to dictate the how a flight is managed, then they should share the responsibility when it all goes pear shaped.   It would help if the HR people could adjust the settings so that pilots who can say NO and are not easily intimidated are hired. 

You see, I am intrigued that the crew of two major carriers could not 'see' that with the forecast conditions, time of year and day that fog was, potentially, on the cards.  Sure the flight was technically 'legal' but, I wonder how many crews did slide an extra 30 minutes for Mum inboard, just to be sure.  Then there is the question of why both flights, with fore knowledge each sailed past viable, fog free alternates.  There are many valid questions which demand answers; but relying on a PC approach is cheap, gutless and of no value to the travelling public.  It is indeed, beyond all reason.

Reason must be restored, ICAO tenets must be restored, but most of all, the ATSB must be restored to being an independent, valuable, productive, fearless defence system for the travelling public.  At present, it is about as much use as my Grand Mama's fat, ancient, toothless, blind, deaf Cocker spaniel trying to yard yearling bullocks. 

The Uriah Heep of aviation safety, inventor of the PC accident investigations cannot be protected, not any longer. The Pel-Air re investigation provides more than enough evidence that this leopard will not change its spots. Unqualified, ignorant, arrogant and operating under top cover is not what the leader of a NTSB should be; but there it sits, smiling.   How in the seven hells it survived the Senate inquiry I'll never know, but there it sits; still smiling for the cameras, dribbling spaghetti sauce.  Well done Minuscle: merde !!  but you can pick 'em.  

The character is notable for his cloying humility, obsequiousness, and insincerity, making frequent references to his own "'humbleness". His name has become synonymous with being a yes man.[1] He is the central antagonist of the latter part of the book. - Wiki.

[url=http://en.wikipedia.org/wiki/Uriah_Heep][/url]

Toot toot. (Half steam).....

[Peetwo]

...It is becoming farcical to the point where, as said previously, why don't we just hire a technical writer to draft half a dozen pro-forma reports, which can at least be published on time.  When you start deconstructing the pitiful efforts of the ATSB accident reports, that's what they boil down to.  A little bit of ATSB fluffy technical analysis, the summary written by a CASA word weasel, couple of pictures and, job done.   Said it all before – HERE - ...

"...This business at Mildura could have ended in tears, except the gods were benign and the weather was willing to cooperate.  The message was clear- ignore this warning at your own peril.  The NTSB or TSBC would by now have their interim reports and more than likely at least three SR out, for discussion with the agencies concerned.  We get a teddy bears picnic, some happy clappy, tent revival with tambourines at the corporate love in.  The whole thing buried under a pile of used soft white paper and wrapped in time.  This ensures that no one will want to pick up the mess and it will, conveniently, with the passage of time, be forgotten..."

Corporate attitudes need retro-modification to realise that the PIC, not the bloody bean counters command the aircraft.  If the BC want to dictate the how a flight is managed, then they should share the responsibility when it all goes pear shaped.   It would help if the HR people could adjust the settings so that pilots who can say NO and are not easily intimidated are hired. 

...You see, I am intrigued that the crew of two major carriers could not 'see' that with the forecast conditions, time of year and day that fog was, potentially, on the cards.  Sure the flight was technically 'legal' but, I wonder how many crews did slide an extra 30 minutes for Mum inboard, just to be sure.  Then there is the question of why both flights, with fore knowledge each sailed past viable, fog free alternates.  There are many valid questions which demand answers; but relying on a PC approach is cheap, gutless and of no value to the travelling public.  It is indeed, beyond all reason...

...The Uriah Heep of aviation safety, inventor of the PC accident investigations cannot be protected, not any longer. The Pel-Air re investigation provides more than enough evidence that this leopard will not change its spots. Unqualified, ignorant, arrogant and operating under top cover is not what the leader of a NTSB should be; but there it sits, smiling.   How in the seven hells it survived the Senate inquiry I'll never know, but there it sits; still smiling for the cameras, dribbling spaghetti sauce.  Well done Minuscle: merde !!  but you can pick 'em.  

The character is notable for his cloying humility, obsequiousness, and insincerity, making frequent references to his own "'humbleness". His name has become synonymous with being a yes man.[1] He is the central antagonist of the latter part of the book. - Wiki.

Toot toot. (Half steam).....

Excellent spleen vent "K" shame we can't transmogrify that pretty blunt message into our vacant headed miniscule, who is being seriously misled by the murky, Mandarin Mrdak....

From over on Skimore Corner Gobbles IMO sums it up quite nicely... 

"...Farmer Truss and his sidekick Pumpkin Head will be giggling away at yet another finding against CAsA that they will pop into the top drawer along with all the other recommendations, and no doubt the top drawer will be emptied when there is a shortage of pot plant base newspaper, or when there is a shortage of shitter paper in the Execs toilet.

I do find it interesting the number of deaths however, and Australia does not have an enviable GA record which does make one wonder whether we are capturing systemic issues below the ice flow or whether we are concentrating on what we can see poking above the waterline? Oh silly question, silly me.

To be honest the small end of town has been deficient for some time, it's just that it gets swept beneath the carpet. Yet tell that to the loved ones of those killed in some of these avoidable accidents. And of course the media only care about the crumpling of large tin, the Government only cares about accidents at a level that brings it bad publicity, and those in GA with big voices who are proactive only get shut down and shut up by the powers to be..."
 
If the truth be known the big end of town and the Sky Gods are more than capable of looking after themselves, it is the small end of town that gets shafted the most by the current status quo in aviation safety administration in this country.

Off another discarded & forgotten UP thread, that was IMO of excellent value i.e. ATSB reports, are two posts of relevance from Old Akro

First:

ATSB reports

---

There was not the usual flood of reports at the end of July. There are now 87 outstanding reports. The oldest of which goes back to 30 June 2011 (Operational non compliance of VH-VNC near Avalon Airport). There were 10 new occurrences in July, but only 5 reports issued.

Even what look like simple reports (eg AO-2012-042 - PA34 descending below LSA at Townsville) are taking over a year.

If you take the ATSB budget and divide by the number of reports (air, sea & land) the average reports costs more than $200,000. Surely even McKinsey & Co would be cheaper and faster.

Last:

Just reading the Feb 20 batch of ATSB reports.

Seriously, have they sub contracted this to Mills & Boon? Or is the work experience kid writing them?

I understand the ATSB's new no-fault policy. But surely if there is no learning or lessons from a report - then why are we bothering?

After a mid air collision is the best advice / recommendation we can muster to read a 5 year old ATSB brochure "A pilot’s guide to staying safe in the vicinity of non-towered aerodromes."

And of course the really funny thing is that the ATSB report

http://www.atsb.gov.au/media/4533008...-205_final.pdf

has a dead link to its recommended "safety message" document. Are we really paying these people?

I've tried searching the ATSB site on both the title of this publication and its ATSB publication number with no luck. It appears that it has been removed from their website. Really doesn't look like they care much, does it?

Surely a mid air collision at a significant capital city airport deserves something more insightful? Where is the value in producing this type of report at all? Why not save the money and just stop doing these mindless investigations?

And from the same UP thread, the following is a post of mine that IMO highlights perfectly how much the ATSB has drifted from the Annex 13 principles and it's original remit when compared in this case to the TSBC:

TSBC in-flight breakup report a benchmark for ATsB??

---

Hmm..has Beaker inadvertently provided us with a template for a future re-modelled ATsB??

Most of us have been dubious (including Senator X #34) of Beaker's real intentions for calling in TSB Canada, whatever his original intentions it has been enlightening to look at how another TSI agency operates.

The TSBC are a no fuss, principled, extremely competent AAI agency that goes about it's business without fear nor favour nor fanfare...

In reference to my previous post:

Two updates on the investigation page today could possibly suggest a disturbing trend...but then again probably not..:

Quote:
AO-2013-226
In-flight breakup involving de Havilland DH-82, Tiger Moth, VH-TSG, near South Stradbroke Island, Qld on 16 December 2013

16 Dec 2013

Pending

23 Dec 2013

AO-2013-187
In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013

24 Oct 2013

Interim Factual

23 Dec 2013

The TSBC recently released a final report into another tragic in-flight breakup accident, that IMO should set the benchmark for the two ATsB investigations mentioned above....

Aviation Investigation Report A11W0048

With equal weight the TSBC systematically examine all the possible causal factors (all the holes in the cheese) and end up with the following in their safety action section:

4.0 Safety action

4.1 Safety action taken

4.1.1 The Federal Aviation Administration

On 25 May 2011 the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2011-12-02. Effective on 02 June 2011, the AD applied to Viking Air Limited Model DHC-3 Otter airplanes (all serial numbers) that were equipped with a Honeywell TPE331-10 or -12JR turboprop engine installed per Supplemental Type Certificate (STC) SA09866SC (Texas Turbines Conversions, Inc.) and certified in any category.

The AD was prompted by analysis that showed airspeed limitations for the affected airplanes were not adjusted for the installation of a turboprop engine as stated in the regulations. The AD was issued to prevent the loss of airplane structural integrity due to the affected airplanes being able to operate at speeds exceeding those determined to be safe by the FAA.

The AD imposed a maximum operating speed (VMO) of 144 mph for DHC-3 Otter land/ski aircraft and 134 mph (VMO) for DHC-3 Otter seaplanes. Footnote 17

On 19 August 2011 the FAA issued AD 2011-18-11, which became effective on 03 October 2011. The AD applied to all Viking Air Limited Model DHC-3 Otter airplanes that were certified in any category. The AD resulted from an evaluation of revisions to the manufacturer's maintenance manual that added new repetitive inspections to the elevator control tabs. The AD stated that if these inspections were not done, excessive free-play in the elevator control tabs could develop. That condition could lead to loss of tab control linkage and severe elevator flutter, which could lead to a loss of control. Footnote 18

 
Tough act to follow...where's your money on the bureau, in it's current diabolical state of disfunction under Beaker, showing the same due diligence of the two in-flight breakup accident investigations listed above??

 
Considering those posts are more than a year old not much has changed the..Beyond All Sensible Reason (BASR)..Beaker/Uriah Heap/Dolan is still in charge; the bureau is still conducting deficient, politically corrected investigations and; still putting out absolute crap reports.

So is the ATSB redeemable?? Time will tell but the current miniscule definitely doesn't have the testicular fortitude to put things right and go against the self-serving advice of his Murky Mandarin.

MTF...P2  

Ps Come on Barnaby you know you want it??

[Peetwo]

P2 - Off another discarded & forgotten UP thread, that was IMO of excellent value i.e. ATSB reports, are two posts of relevance from Old Akro

While I'm raiding that UP thread I thought it worthwhile regurgitating 4 posts off page 2 that partly explains the slide of the bureau. It is for mine extremely sad that the BASI/ATSB has gone from a small, poorly resourced air safety watchdog that used to punch well above its weight and was held in high esteem throughout the aviation safety fraternity worldwide; to an insipid non-independent AAI that panders to the political/commercial interests of various DIPs to higher profile investigations, while playing submissive lapdog to the big R regulator behemoth CASA...   

Sarcs

The Beaker years – ‘beyond all sensible reason’ (addendum to “K” #32 )

--------------------------------------------------------------------------------

Glad to see the mods have merged these two threads it kind of sets a background to the demise and hit to the reputation of the once proud aviation safety watchdog, the ATSB/BASI.

The bureau, much like Fort Fumble, has always had its detractors but even the critics would (once upon a time) grudgingly admit that on the whole the ATSB generally get it right and make a worthwhile contribution for the betterment of aviation safety. However IMO in the last 5 years they have seriously lost their way. The evidence of this was very much on display throughout the Senate Inquiry (hence *Recommendation 8). Also, as posters on here are noticing, through the quality of the reports being produced. The mantra now appears to be…politically correct and on budget.

*R8. The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee.

Note: Beaker attempted to placate the Senators by bringing in the Canucks but Senator Fawcett rather scathingly struck back with this comment in a press release…
“While the engagement of the Canadian TSB is welcome, the gravity of the issues raised in the Senate report means that the Minister should be overseeing the review with the support of an expert panel rather than the ATSB,” Senator Fawcett said.
“It is critical that this review of the ATSB is allowed to examine all sensitive areas of the ATSB investigation processes as identified in the Senate report including the Canley Vale accident.”

Some would say this decline of the bureau can be tracked back to the Lockhart River investigation with the subsequent Coroner’s findings through to the Miller review. However IMO, despite all those troubling times, the bureau on the whole could still hold their heads up high till at least the middle part of 2008.

Perhaps to highlight this there were two important report publications put out by the ATSB in 2008-09, one was the decade review; Australian Aviation Safety in Review: 1998 to 2007 and the other (internationally recognised) was the worldwide review of commercial jet aircraft runway excursions.

In the foreword of the Aviation Safety Review the former and last Executive Director Kym Bills (rather proudly) had this to say:

It has been an exciting and progressive year for air safety in Australia. The December 2008 release of the National Aviation Policy Green Paper established the future direction of the aviation industry, asserting the Government’s position on air safety in Australia as the number one priority. This includes the establishment of the Australian Transport Safety Bureau (ATSB) as a statutory agency with a Commission structure to enhance its independence. Legislative amendments to the Transport Safety Investigation Act 2003 to give effect to the governance changes have been passed by Parliament and the new Commission will come into place on 1 July 2009.

I am delighted to release the third edition of the ATSB’s Australian Aviation Safety in Review. The format of this edition departs from that of the first two editions to provide a range of new information not previously presented. The report provides an overview of the aviation industry with a focus on safety data derived from aviation occurrences reported to the ATSB. It covers a
10-year period (1998 to 2007) and describes trends and analysis of both aviation incidents and accidents.

The first chapter deals with the structure and size of Australia’s aviation sector, including the number of aircraft registered and numbers of pilots and engineers licensed, and the amount aviation activity in different sectors. The next two chapters delve into measures of aviation safety. Chapter 2 examines the trends across 10 years for the number of fatal accidents, accidents and incidents, and their rate expressed as a proportion of annual flying hours. Chapter 3 takes a closer look at the nature of aviation occurrences (incidents and accidents) in Australia through an analysis of what occurred. Chapter 4 looks at why they occurred. That is, what human actions and technical failures contributed to the occurrences. Aviation occurrence reporting requirements and procedures are described in Chapter 5, and in Chapter 6, the special topic covered is the issue of birdstrikes in airline operations.

The information in this report is a valuable contribution to the advancement of the aviation safety in Australia. I trust it provides a helpful reference to assist those seeking to understand the big picture about the safety of Australia’s aviation sector. By better understanding the accident and incident trends and analysis in aviation, we can work together to strengthen Australia’s position as a world leader in aviation safety.

I commend the report to you.

Kym Bills
Executive Director
Australian Transport Safety Bureau

Note: I wonder on reflection whether KB would have made the same statement today?? And does he feel somewhat betrayed by the turn of events that was to occur since the end of his tenure at the ATSB??  

The other report/review is still highly regarded internationally as a reference for jet runway excursions and is incorporated into an ICAO/FSF report on Reducing the Risk Runway Excursions.

As an example of the worth of this excellent proactive report and the knock on safety benefits, lessons learnt etc..etc our fellow Canuck comrades, the TSB Canada, have just released a final report into a Quebec runway excursion by an American Airlines 737: Aviation Investigation Report A10Q0213.

Note: This excemplary and very informative report is worth taking the time to read and you will find that in the web portal format is extremely easy to navigate around. You will also observe that the ICAO/FSF is listed as a reference and that the ATSB database on similar B737 incidents is referred to in appendix G.

Extract from Safety Action section of this report:

Safety action taken

American Airlines

In April 2011, as part of its pilots’ recurrent training, human-factors class, American Airlines introduced a simulation and discussion of this Boeing 737 runway excursion. This training is given to company pilots to educate them on the possibility of a runway excursion due to a nosewheel steering problem on landing roll-out after a normal approach and landing.

Safety concern

Despite efforts in analyzing past nose-gear steering, low-slew rate-jam events and carrying out post-event valve examinations, the cause of these uncommanded steering events remains uncertain. The safety review process completed by the manufacturer and based on a quantitative, cycle-based occurrence rate of 1 X 10-7, classified this event as an extremely remote probability, and gave it an acceptable risk level, combined with a major severity level. An occurrence rate of 1 X 10-7 meets the Federal Aviation Regulations (FARs) certification requirements. Additionally, an acceptable level of risk does not require further tracking of the hazard in the Federal Aviation Administration (FAA) Hazard Tracking System. Consequently, other than flight data analysis and valve examination, the manufacturer has not taken further action following the 11 known nose-gear steering rate-jam events that have occurred over the past 21 years.

Rate of occurrence determines whether a manufacturer needs to take safety action. In order to determine the rate of occurrence, there is a need to capture as many events as possible. This capture allows identification of possible safety deficiencies, and aids in the application of risk-mitigation strategies. Since no defences have been put in place to mitigate the risk of a runway excursion following a rate jam, damage to aircraft and injury to aircraft occupants remains a possibility.

The present known low rate of nose-gear steering rate jams may be explained by the fact that, directional control difficulties on take-off or landing would not often result in an excursion and/or damage or injury, and therefore would not be reported. The lack of reporting may also be due, in part, to the fact that operators, flight crew and maintenance personnel have not been made aware of the possibility of rate-jam events, nor have they been provided information on how to recognize, react or troubleshoot. The rate of occurrence would have to show a significant increase to validate corrective action, as safety action is based on FARs certification and in-service fleet following requirements.

Despite technological advancements in recording devices, many Boeing aircraft do not record nosewheel steering system parameters. Boeing models affected include 707/720, 727, 737, 747 (some models), 757, 767, and 777.

The cause of these low-slew, nose-gear steering rate jams over the past 21 years remains uncertain. A lack of recognition and reporting prevents adequate data collection, analysis, and implementation of risk-mitigation strategies if necessary.
The Board is concerned that, in the absence of information as to the cause of uncommanded steering events due to nose-gear steering rate jams, there remains a risk for runway excursions to occur.  

The safety action section shows the benefits or flow on affect of compiling worldwide information, including the ATSB review and draws attention to a possible safety issue on B737 aircraft that will now be noted (at least) on the TSB database. It also reinforces the ICAO/FSF initiative to create a Runway Excursion Database.

So the question is can our bureau recover from the Beaker years and return to some of its former glory as a proactive AAI organisation at the forefront of contributing to aviation safety worldwide, or are we to continue with these politically correct, fiscally accountable, dribble of reports that have no substance or relevant safety recommendations attached?? If it is the latter then industry and taxpayers deserve a refund and our once proud safety watchdog should be disbanded! Minister it is your call but please take account of the disturbing findings in the PelAir inquiry and action a government response to the partisan Senators recommendations ASAP… 

Centaurus

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers

Interesting observation re the vast experience needed nowadays to write a report. I am sure it has changed now in the RAAF but during my time there in another era, accident investigations were over and done with within one month to three months.

Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could.

One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around.

Old Akro

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.

It takes years of experience to apply a wind vector as a tailwind before & after a 180 deg turn? Or produce different wording for the transcripts of radio calls between the initial, preliminary and final reports?

Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review.

Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports.

This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k.

Kharon

Longish post warning

--------------------------------------------------------------------------------

OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa.

It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).

"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.

The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.

I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.

When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.

It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.

The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..

Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did.

Senator FAWCETT: Does this report make any recommendations for improvements?

Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.

Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.

I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions....

Hmm...again remember that those posts were written nearly 18 months ago, sad indictment on our democratic system maybe but remember this is posthumously recorded on an internet server near you miniscule.. TICK..TOCK...P2

[P7_TOM]

In the interests of investigative probity.

Just read the Paul Howard modest offering on Paper-Li – HERE – It's not dripping with 'conjecture' or high blown theory; just a workman like series, a practical mans approaches to solving the early riddles.  It raises the sort of questions a logical person would ask; simply to eliminate dead ends, false starts and widely spaced breadcrumbs.  The answers may not be correct, which is fine – provided they can be discounted after 'expert' assessment, based on known facts; but, as it stands, he makes just as much good sense as any and a damn site more than many others.  

In the interests of investigative probity, can Be-a-Cur confirm that the calculations are proven flawed and have been discounted after examination; or are they just another tendentious, waste of time line of inquiry which has been summarily dismissed, by qualified experts, such as himself?.  Don't hold your breath, we use the beyond all reason method and talk to Unicorns.  Perhaps he could read some Howard and enjoy some logical, professional food for thought, as a how to lesson and see what 'investigating' means.  

....This is vitally important in determining what was seen. NOTHING was seen in real time. ALL radar is from recordings and NOT anecdotal from individual operators. Recordings are able to be very specific about one thing, POSITION and that is exactly what’s missing from the Interim Report. Why?

.....I’ve transferred that information on to my own plot as best I can and remember my comment earlier, the one definitive piece of information which can be derived from a radar recording is position and that is exactly the information which is missing.

[Peetwo]

Disingenuous? ATSB?, Oh you bet.

As forecast by Aunty Pru, Beaker leads the way.  The ATSB cannot be trusted to reinvestigate the Pel-Air ditching let alone the manipulation of the manipulated final report.  This is the crowd 'helping' the Malaysian government.  The question; just how are they helping, begs answer. 

The Sheik's disturbing post only gives an inkling of the duplicitous nature of the ATSB management ethos, which is fully supported by the government DoIT and by extension, the Minister.  Manning, the new boy is conspicuous by his absence; meanwhile the ubiquitous Uriah Heep continues his on his merry way, unashamed by the Pel-Air report, the Senate Inquiry or the TSBC peer review.  The thing that  really gets me cranky is this benighted industry will, passively sit back and let 'em get away with it: MILDURA; ATR 1; ATR 2; REX 1,  all outstanding examples of how to PC air safety into a 'DIY', in house side line for Safety Management Systems.  

You wait for the company concerned to fix it; wait for CASA to decide if there is a juicy prosecution available; wait until the airline has covered it's arse: then, trot out a fluffy report which says, what happened, what has been done and that all parties are thrilled to bits.  Who needs the ATSB then? no one is the answer, they can just hire a technical writer to mop up, save a fortune and play golf whenever they like (tax payers expense of course) The peer organisations such as NTSB and TSBC must be watching closely; for they too, like a game of golf.  

Here are some of the concerns which PAIN registered with the Senate during the Pel-Air inquiry; still valid, still virginal and still, as yet, unanswered.  We just hope they have done their homework as well as the PAIN research crew have. The questions will be answered then by Golly..   Supplementary submission – HERE – from the AP library.  

Ok, ok, -STEAM OFF.  Well, honestly; etc. etc.   

Toot toot..

In between the time that Senator X called for the Pelair inquiry..

Information about the Inquiry


On 13 September 2012 the Senate referred the following matter to the Senate Standing Committees on Rural and Regional Affairs and Transport for inquiry and report.

Submissions should be received by 12 October 2012. The reporting date is 29 November 2012. On 30 April 2013,the Senate granted an extension of time for reporting until 23 May 2013.

The Committee is seeking written submissions from interested individuals and organisations preferably in electronic form submitted online or sent by email to rrat.sen@aph.gov.au as an attached Adobe PDF or MS Word format document. The email must include full postal address and contact details.

...and the first public hearing on 22 October 2012 there was much conjecture on the UP and on various tendentious blogger sites on what would be revealed (or not) on the latest in a long line of Aviation Safety related Senate inquiries.

On one particular day - the 23 September 2012 - PlaneTalking made no less than two posts in relation to the upcoming PelAir inquiry. It just so happened that on the UP I noted & recorded both of these posts. Now upon reflection and in the interests of ATSB investigative probity - with regard to the current bureau PelAir reinvestigation - here is both my UP posts that reproduce IMO these very relevant PlaneTalking articles:

Well, well, well....sure is quiet on PPRuNe lately, hopefully everyone is busy writing up their submissions for the upcoming Senate Inquiry well here's a bit of goss that may help fire up the neurons:

From Planetalking Sep 23, 2012 4:05PM:

Earlier today an article about rumors that the ATSB final report into the Pel-Air ditching was being withdrawn or revised was denied by a Ministerial spokesperson.

But in the course of this an explanation of the RVSM or reduced vertical separation minima was provided, and is published below:

· Non-RVSM-equipped ambulance aircraft can be cleared by NZ ATC into RVSM airspace, should traffic allow and the necessary altitude ‘buffers’ be available.
· In this case the aircraft had been cleared by ATC to cruise within NZ/Pacific RVSM airspace, at FL350.
· After initially being cleared by ATC at FL350, the aircraft was instructed to descend to FL270 due crossing traffic. Being conscious of the increased fuel burn at the lower altitude of FL270, the crew requested and was subsequently re-cleared by ATC to climb to FL390. This was maintained until descent into Norfolk Island. Once at FL390, the crew reassessed their fuel remaining and set a lower thrust setting to satisfy themselves that they had sufficient to complete the flight with the necessary reserves intact.

This is further evidence as to how this ATSB report is a disgrace.

Nowhere in the report is RVSM even mentioned. It is very obvious in the ATSB report that the there is a place in the narrative where the words reduced vertical separation minima ought to have appeared.

Why didn’t they appear? Could it be that the report avoided or expunged this term so as to avoid alerting the curious reader to the fact that the Pel-Air jet which routinely used this non-RVSM airspace was not equipped to use it as a matter of course?

Might that have then caused the curious to turn to the standard operating procedures quoted by the ATSB and discover that there is no contingency written into them for a need to exit RVSM airspace, and that the fuel burn figures pointed to by the ATSB have even less relevance to the situation the pilot was put in by the operator that CASA so woefully failed to supervise?

This illustrates why this report is so bad. It is designed to steer the reader away from asking questions that would embarrass the operator, or from asking further questions about the quality of its oversight by CASA.

The ATSB has already been caught out publishing incorrect information about the meteorological information provided to the pilot, which was picked up in the 4 Corners report and dealt with there.

Its inability or reluctance to even mention RVSM or the certification of the pilot to land at Noumea in the event of a diversion is telling.

This report is going to be examined in minute detail in the Nick Xenophon instigated Senate committee hearings into it and related matters.

It is reasonable to anticipate that the operational history of Pel-Air medical repositioning flights in this part of the Pacific, including diversions to Noumea which caused friction with its civil aviation authority because of the level of equipment present on its aircraft will be discussed under parliamentary privilege.

Indeed there is a real prospect that the hearings will carry out the job that the ATSB either failed to do, or was unable to bring itself to do because of the adverse effects that may have eventuated for Pel-Air.

And hey this is not an isolated case of a substandard, ulterior motive ATSB 'Final Report'...hmm it's just one that has grabbed a certain amount of mainstream media and public interest!

ps Don't know if I'm really taken by the new format at Crikey!

New evidence that the ATSB Pel-Air crash report is flawed | Plane Talking 

     
& then a couple of hours later... :

Update to the update!

---

Planetalking sure is firing up about all this:
Quote:
*Publication of this post has produced a categorical denial from a Ministerial spokesperson that the ATSB report in question is being replaced or amended.
Of course those who read this post will become aware that this is not the real issue, which is the disgraceful quality of the report that the ATSB issued.

There are rumors circulating that the ATSB final report into the Pel-Air medical evacuation flight ditching near Norfolk Island in November 2009 is to be withdrawn and replaced with a new report.

The Minister for Infrastructure and Transport, Anthony Albanese’s media officers have not responded to a query about the validity or otherwise of this rumor since Saturday morning.

If the rumors are true, it will an heroic admission of exceedingly serious failures on the part of the ATSB, the air safety investigator, and reflect very adversely on CASA, the air safety regulator.

It would also follow from such an admission that both bodies would undergo some serious changes in management and conduct in order to restore Australia’s reputation as a level one state in terms of air safety administration.

If however the rumors are untrue, or there is instead a ‘final’ final report being prepared, which will attempt to repair the damage to process and institutional reputation done by the ‘no longer final’ final report, as well as to the captain of the flight, both bodies will struggle to regain credibility and respect from many stakeholders in aviation in Australia, as well as in the eyes of peer organisations, including ICAO and the FAA.

One way of analyzing the performance of the ATSB and CASA in relation to Pel-Air is to look at how the final report was constructed to load almost the entire blame for the accident on the captain for having inadequately fueled the small Westwind jet for first stage of its medical retrieval flight which was from Apia to Norfolk Island, where it was to refuel and continue to Melbourne, carrying the two pilots, two passengers and two medical professionals.

But even though the ATSB quoted at length Pel-Air’s operating manual for the flight, including the fuel calculations based on its flying at an optimal altitude, it fails to mention anywhere that the jet had not been upgraded to allow it to fly through much of the oceanic airspace it was to traverse at such altitudes under the rules applying to reduced vertical separation minima or RVSM.

Nor could the jet legally plan for or make a fuel diversion to Noumea as it encountered stronger than expected headwinds and higher fuel use because of the RVSM issue because Pel-Air had not trained the pilot to use New Caledonia airspace, which as a special jurisdiction affiliated with France, uses European air space regulations.

Neither of these critical matters are mentioned anywhere in the report. But they were raised with the investigating officers. The significance of both matters could not fail to be apparent to CASA or the ATSB, making inescapable a conclusion that both bodies were averse to making detrimental findings about the operator and had thus unjustly and deliberately focused all of their negative findings on the pilot.

For the two most important bodies in the public administration of aviation safety in Australia to conduct themselves in this manner is grossly improper.

The captain, Dominic James, was being directed by an airline CASA failed to properly regulate, to fly an oceanic route according to a fuel rule that CASA ought never to have approved, according to standard operating procedures for an altitude unavailable for much of the distance because it wasn’t RVSM equipped, and had not been trained to the regulatory standard required to use New Caledonia airspace in the event a diversion to Noumea, which some have criticised him for not using.
Much of the context for this is made lay friendly by the ABC TV 4 Corners report into the crash. But on its website, under background documents at the above link, 4 Corners also posts a CASA audit of Pel-Air which took place, as had been scheduled before the crash, shortly after the crash.

This audit found multiple serious safety deficiencies in Pel-Air’s operations at the time of the crash. Yet in its previous audit of Pel-Air CASA didn’t find much at all, leaving viewers to wonder whether the operator suffered a precipitous decline in standards in that period, which would surely have required an immediate grounding Tiger style, in the interests of public safety, or whether CASA audits are fundamentally useless before the fact.
The 4 Corner’s program site also hosts uncut videos of interviews with CASA’s director of safety, John McCormick, and the chief commissioner of the ATSB, Martin Dolan. Both interviews are shocking reflections on the processes and attitudes at these vital aviation authorities.

Dolan’s performance is more than 18 minutes of severely compromised testimony, in that he seems utterly unwilling to even acknowledge that CASA found more than 20 safety deficiencies were in effect at Pel-Air at the time of the crash or that they had anything to do with the accident.

Dolan and McCormick are well aware, and on the public record as being aware, that it is the airline or the operator that is ultimately responsible for the flight standards that are delivered to, or upon, the public.

This concept of airline or operator responsibility is the foundation stone of air safety regulation in the developed world. It has been trashed in Australia by this disgraceful ATSB report into the Pel-Air crash.

The performance of CASA and the ATSB in particular has been exposed as severely and dangerously deficient by the Pel-Air report and its aftermath.
One way or another, and without delay, these deficiencies must be remedied.
Oh there is some awful murky waters loaded with pony pooh to navigate before we get to the guts of all this me thinks...scratching my sore noggin!

Yeah Blackie and I forgot to mention the 'Beaker from the Bureau'....hmm that would be a.. on cozying upto that numbnut!

Hmm...it would appear that I didn't think much of Beaker back then either.. ..& is Ben Sandilands a soothsayer all something...

It is also interesting to see the political process with Albo's toing & froing...err bollocks & bullshit and how that is now being replicated by Farmer Truss & co...FFS

However more importantly is the part on the RVSM in Ben's 1st post that on the 2nd (or is it 3rd??) time around should not be again neglected to be reviewed, along with all those other awkward operational/organisational contributory factors, like for example err...regulatory oversight...

MTF...P2   

 

[Kharon]

P2 -  [should] not be again neglected to be reviewed, along with all those other awkward operational/organisational contributory factors, like for example,  Err...regulatory oversight.

From the PAIN Lockhart river report:-

...The Civil Aviation Regulations require that an air operator provide an exposition; usually entitled the Company Operations Manual (or similar) it is required, by strict liability law carrying criminal penalties to provide detailed operational support data.  The exercise is designed to produce a 'rock solid' foundation supporting all facets of the proposed Air Operator Certificate (AOC).  

....The CASA for the last few years have blurred the distinction as to whether the exposition is "accepted" or "approved".  Notwithstanding the fine legal distinctions made, in reality, if the Flight Operations Inspector drafting the approval does not "like" what is presented the manual will neither be accepted or approved.  In short, the CASA delegate 'must be satisfied'.  etc.

It will be interesting to observe how the ATSB 'manage' the regulators role in the Pel-Air fiasco.   Take the RVSM questions as one of the many aberrations the flight crew were forced to deal with.  To gain approval for operations in RVSM airspace there is a list of 'requirements' (operational and engineering) a mile long to meet, then the whole endless process of having CASA approve the proposed system; then there are dedicated protocols and procedures for aircrew to learn, be examined in and an approval must be issued.  Every step must 'satisfy' CASA.  Should the company not have the approval, then aircrew are obliged to flight plan for operations in Non RVSM airspace.  This requires clear policy and instruction to be provided in the fuel planning section of the approved/accepted company operations manual.  Pel-Air had neither.  

Yes, the company Chief pilot (responsible) should have picked up the deficiency, but did not.

CASA as the last link in the safety chain should have picked it up at audit; but did not.

Had the company approached CASA with an amended fuel planning policy for 'acceptance' then perhaps things would have turned out differently.

Had CASA identified a 'gap' in the safety net and brought it to the company attention; then, things may have turned out differently.

Who's to bless and who's to blame? well there's a choice isn't there.  But if you put blame aside and focus on 'fixing' the problem; closing the loop: there are at least three recommendations which could be offered by the ATSB to prevent a reoccurrence.   The big questions are – will they make those recommendations? – can they make them stick? – will CASA be obliged to 'fix' their wagon? – will the operator be audited to make sure the 'fix' is effective?

Big job for the ATSB and RVSM is just one area.  The Norfolk ditching touches nearly every facet of the 'safety net'; from fatigue to flame out.  The final question of course is – can the ATSB do the job without external assistance?   Not if we are to have a honest, credible answer they can't – who would believe them?  They are, after all investigating their own murky part as a major player in a very moody passage of play, some clumsy sleight of hand, being economical with the truth and trying to bluff a Senate full house with two pair.

No matter, we shall see the result of their internal efforts, in another year or two.  No rush.

Selah.

[Peetwo]

P2 - Off another discarded & forgotten UP thread, that was IMO of excellent value i.e. ATSB reports, are two posts of relevance from Old Akro

While I'm raiding that UP thread I thought it worthwhile regurgitating 4 posts off page 2 that partly explains the slide of the bureau. It is for mine extremely sad that the BASI/ATSB has gone from a small, poorly resourced air safety watchdog that used to punch well above its weight and was held in high esteem throughout the aviation safety fraternity worldwide; to an insipid non-independent AAI that panders to the political/commercial interests of various DIPs to higher profile investigations, while playing submissive lapdog to the big R regulator behemoth CASA...   

Centaurus

Not just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers  

Interesting observation re the vast experience needed nowadays to write a report. I am sure it has changed now in the RAAF but during my time there in another era, accident investigations were over and done with within one month to three months.

Having said that, there was no such position as a professional accident investigator in the RAAF. A prang occurred and you would be allotted to investigate what caused it. It was called a Court of Inquiry. As a General Duties RAAF pilot it was expected you would fall back on your experience of flying that aircraft type and common sense. Suitable resources were at your disposal. Of course there were no CVR or FDR's then, so you and your team would scratch your heads and do the best you could.

One thing for sure. There was no going on recreation leave causing long periods of inactivity during the investigation and I don't recall the legal eagles agonising over the wording of the report to cover possible future litigation. In other words Courts of Inquiry didn't stuff around.

Old Akro

No just any pilot or engineer can just walk in the ATSB's front door and start generating suitable reports, it takes years of experience - even for highly experienced pilots and engineers.  

It takes years of experience to apply a wind vector as a tailwind before & after a 180 deg turn? Or produce different wording for the transcripts of radio calls between the initial, preliminary and final reports?

Most ATSB reports lack fundamental understanding of scientific method. They are typically not transparent and fail to provide enough primary data to allow review.

Furthermore, when serious technical investigation is required now, its typically done overseas with the engine or airframe manufacturer. And any report with detailed technical involvement - or controversy now takes over 2 years to produce. You don't need "years of experience"to investigate a C172 taxying a wingtip into a pole, which is the level that makes up the bulk of the released reports.

This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa. For $24.8m we got 162 safety investigations - 60 complex ones which take a median of 458 days and 102 "short"investigations which took a median of 84 days. The average cost is $153,000 each. Have a look at any of the reports published in the last 3 months and consider whether any of them are worth $150k.

Kharon

Longish post warning

--------------------------------------------------------------------------------

OA # 37 "This is an organisation that cost us $24.8m last year. 64 out of 116 employees are paid over $108,000 pa.

 
It's annoying, we spend so much money 'front of house' and ignore the good work done 'in house'; one of the AIPA members made a submission into the pilot training inquiry, there is a very good passage in the submission which highlights several subtle, but important 'bumps in the road'. Sorry no link to the whole thing, just a crib from my copy. (Hint).

"Safety department when the Jetstar incident occurred although I was on leave during August 2007. The incident was reported by the pilots to Jetstar Safety and it was subsequently reported to the ATSB. The data recorded by the aircraft during the incident was stored on a Quick Access Recorder which had to be removed from the aircraft and the data sent to Qantas. Qantas processed all Jetstar QAR information as Jetstar do not have the resources to conduct this process. Qantas informed Jetstar in August that the QAR data indicated that a Ground Proximity Warning had occurred. Jetstar Flight Operations Management then requested further information and commenced an internal investigation although at this stage the investigation focused on incorrect use of the TOGA function and the June 2007 incident was one of three incidents.

The other two incidents involved a missed handled go-around in Avalon and a long landing in Adelaide.

I do not believe that there was a deliberate attempt by Jetstar to conceal information from the ATSB but that there were no protocols that required the ATSB to be informed of subsequent information.

When I returned from leave in September I was tasked with preparing a report that only focused on the June 2007 incident. The Fleet Investigator who had been preparing the report on the three incidents briefed me on what had been done and then he went on four weeks leave.

It was during this time that the incident was reported in the media and the ATSB decided to investigate the incident. It was then accorded significant priority in Jetstar. While I was trying to put together an investigation using my ATSB experience I was diverted from the task when I was advised that the Captain involved in the incident had been contacted by persons claiming to be from the ATSB and were seeking further information regarding the event. This resulted in me having to contact Qantas Security and the ATSB to try and discover who was responsible for the call. The ATSB referred the matter to the AFP but they decided that it was not worth the resources required to pursue the matter.  

The AIPA submission to Pel Air raises some questions from Fawcett, the guys responding took a fairly softly, softly approach (as you'd expect) but still managed to get the message across fairly well. It's a pity when the talent and expertise freely available from airline internal safety investigators is ignored, or treated as biased. Especially when the ATSB prefer to allow the CASA party line to well and truly Wodger a report. My bolding in the quoted parts, click on the Fawcett link for the whole passage..

Capt. Klouth : From where BASI to the initial ATSB was quite a good improvement. Really, the highpoint for ATSB investigations has been Lockhart River and what came out of that. But obviously we are discussing this report and its impact on the general safety tone within Australia. As we mentioned, we are a bit concerned over whether it is now to become the model for future safety reports. As in the AIPA submission, if there is a bigger accident, will the model of this report be applied to a larger accident if that should occur? We would be concerned if it did.

Senator FAWCETT: Does this report make any recommendations for improvements?

Capt. Klouth : Not specific recommendations, no. It outlines safety findings, but the issuance of recommendations is to be a formal process. It would generate its own file and then would be monitored in the system. But this seems to indicate that they rely a lot on the particular regulator or operator to come up with solutions themselves to what is in the report. There does not seem to be any active monitoring of whether the safety actions will be followed through.

Mr Whyte : One of our areas of greatest concern is that there are no formal recommendations that can be opened and then accepted as complete or remain open. And who is reviewing that goes even further in that the safety actions that are listed are not actually actions. They are things that are going to happen sometime. If they were actually in place, I would accept that it is a safety action and can be closed off, but at the moment they are not. It is, 'We are going to issue a notice of proposed rulemaking at some point in the future.' They have not yet, so how can it be a safety action when it has not happened? In terms of improving safety, which is why we are here, certainly one of our greatest concerns is who is developing those recommendations and then monitoring the implementation or accepting that we cannot go there and assessing that process.  I hope the currently in charge outfit consider the information provided and move quickly to stop the rot. I can accept that compared to the other issues they are dealing with, this one is small potatoes, but it could be cleared up, swiftly and efficiently without the need to spend years and millions. I bet the ATSB troops could provide a solution between breakfast and morning tea, perhaps someone should un-muzzle them, and ask the questions.... 

Again I consider it important to reflect on this post & indeed that old but not totally forgotten excellent UP thread - ATSB reports.

This week the ATSB released another Final Report - AO-2013-163 - of a lesser known GA fatal accident that occurred on 23 September 2013 in Hamilton Victoria.

From Oz Flying:

The burnt wreckage of C182 VH-AUT after the aircraft collided with the ground. (ATSB)

ATSB releases Investigation Report into Hamilton Crash
07 May 2015

The Australian Transport Safety Bureau (ATSB) has released its investigation report into the fatal crash of a Cessna 182 at Hamilton in Victoria.

The pilot of VH-AUT was conducting night circuits on 23 September 2013 as part of an airline cadetship when the aircraft crashed after executing a go-around.

"The ATSB found that following an aborted landing during circuit training in dark night conditions, the solo student pilot lost control of the aircraft, resulting in a collision with terrain," the investigation report states. "There was insufficient evidence to determine the reason for the loss of control.

"The student pilot’s post-mortem examination identified a cardiac condition capable of causing incapacitation and their medical history included another condition that, if having effect at the time, had the potential to have contributed to the development of the accident. The Civil Aviation Safety Authority (CASA) was unaware of either condition."
In addition, the ATSB found the C182's flaps were fully extended at impact, which was not consistent with either the operator’s or manufacturer’s procedures for a go-around. However, the investigators were able to determine how or if the flaps contributed to the crash.

Other factors considered were the pilot's past history of Attention Deficit Hyperactivity Disorder (ADHD) and the potential for spatial disorientation.

Having read through this report I cannot but feel that the ATSB has missed yet another golden opportunity to pass on some significant safety lessons from this tragic accident...

Maybe to the further shock & horror of Lefty off the UP.. ..I noticed that Centaurus (from above) has started a thread on this ATSB report. His excellent post more than adequately (& a whole lot more) reflects my sentiments on this Final Report... :

ATSB report on fatal C182 Go-Around at night

---

Investigation: AO-2013-163 - Loss of control and collision with terrain involving Cessna 182 VH-AUT, Hamilton Airport, VIC on 23 September 2013

In Cessna singles, a very low altitude go-around with full flap is a demanding exercise particularly with the strong pitch up that occurs at full throttle. To conduct the exercise under the hood or simulated IMC takes very sound instrument flying skills. On a dark night with no visible horizon, even an experienced pilot would need to be very careful during the initial change to climbing attitude and the change of trim that occurs as flaps are retracted to an intermediate setting and then up.

The nose down trim that occurs as the flaps retract needs to be countered lest the aircraft goes from the initial climb into a gentle descent because of poor instrument cross-reference by the pilot. This manoeuvre needs to be practiced under the hood to simulate loss of forward visibility such as rain or dark night conditions. It is a highly critical manoeuvre on instruments and no student should be sent solo until he has done several runway level go-arounds on instruments and judged to be perfectly competent.

Most pilots will recall the advice by their instructor on being sent for their first solo. It is usually something like "When in any doubt do not hesitate to go-around". That applies whether it is first daylight solo as well as first night solo. Most flying school instructors teach the go-around at around 200 feet and it is probable that very few teach go-arounds from the flare or during the float which is the most critical point with everything hanging out, speed bleeding and maybe even the first few bleats of the stall warning.

This runway level go-around is demanding but needs to be taught as should the recovery and landing ahead on the remaining length should a balloon or high hold off occur. A go-around from several bounces gets increasingly dangerous as speed is close to the stall. for that reason students need to be confident and competent to go-around again from a bounce before first solo day or night as well as equally competent to recover from a bounced landing and re-landing straight ahead.

Disregarding for the moment the ATSB medical report of the students heart condition, I believe ATSB missed a good opportunity to discuss the traps that can occur should a pilot have reason to go-around at very low altitude at night. Spatial disorientation is only one factor. A vitally important factor is the skill of the pilot and how he was taught by his various instructors.

Often, instructors do not adhere to the recommendations published in the manufacturer's AFM or Pilot handbook. Sometimes training schools publish their own procedures rather than the manufacturer's procedures. Physical handling of the go-around especially with regards to trim changes with flaps and the pitch up that occurs during a low speed full flap go-around need to be thoroughly understood by students One of the most effective teaching techniques is by doing the go-arounds at a safe height under the hood in simulated IMC/dark night.

In another era I was a RAAF QFI doing recurrent night flying training in a Lincoln bomber at Townsville on a experienced former wartime bomber pilot. He was much more experienced than me but out of currency on night circuits. After several touch and go landings on Townsville Runway 01, he was instructed to turn right 30 degrees after take off to track over the water east of Magnetic island. Apart from a few lights from houses at Magnetic island it was dark and we were on instruments.

At 800 feet after take off , the right turn was commenced and flap retraction took place. The QFI had no flight instruments in front of him (the Lincoln was designed for single pilot operation) and he had to lean to the left to monitor the pilots instruments which gave significant parallax error problems. As the flaps started to slowly retract from the take off setting, there was the usual nose-down change of trim. The pilot who was fully on instruments because of the dark night and no visible horizon, failed to counter the nose down change of trim and allowed the Lincoln to gently descend with the VSI changing from a 500fpm rate of climb at 5 degrees nose up to 2-300 fpm descent with his AH just below the horizon.

The radio altimeter showed a steady slow descent and it was obvious that the experienced bomber pilot was slow in his instrument scan as he said nothing. At around 500 ft radio altitude above the sea, I called and said "Watch your VSI "Sir". He was a squadron leader and therefore a "Sir" as I was junior in rank even though as QFI, I was captain of the aircraft.

With a muttered oath of surprise, the pilot swiftly pulled back on the control column arresting the descent and we resumed the climb. Nothing was said between us. it didn't have to be as it was clear that he would have allowed the aircraft to descend slowly into the sea. As mentioned earlier he was not current at night and not current on instrument flying which is why we were flying as dual instruction that Townsville night.

If a highly experienced pilot like the squadron leader had troubles on a night departure one can imagine the difficulty a Cessna student pilot at night doing a late go-around with full flap must have had..

  
Top stuff Centaurus...

Definitely MTF..P2

Ps This is not a good look for AVMED  :  

...A CASA aviation medical specialist advised that the standard aviation medical examination procedure for a person of the pilot’s age may not have detected the condition...

...For reasons that could not be conclusively established, CASA was unaware of the student pilot's prior treatment for ADHD. As a result, CASA was unable to determine whether the pilot was free of symptoms prior to beginning their airline pilot cadet scheme and consider any ongoing surveillance of the pilot.

Pooshambolic & Co were probably too busy chasing life threatening CVD Wannabes away from the industry...   

[Kharon]

Just what do you call a cluster of ducks?

Nicely caught P2 – and a time saver; I will see your Centaurus and raise you a Tee Em.  For my money TM raises one of the major items the ATSB hesitates to approach.   Remember who approves/ accepts procedures and checklists.  For students a critical area; who knows,  had the GA been executed as per the manufacturer procedures used during certification the accident would. perhaps, never have occurred.  But I forget, the average CASA FOI knows truck loads more that the manufacturer and their test pilots, sorry my bad. 

TM - The ATSB reproduced a copy of the company procedure for a go-around which stated the configuration should not be changed until a positive rate of climb is first achieved. This differs from the manufacture's procedure that states the flaps must be immediately retracted to 20 degrees from 40 degrees on commencing the go around. 

The manufacturer's recommendation covers the various temperatures that may be encountered in normal service. At high ambient temperatures and other than sea level airports, the aircraft may not be able to maintain a positive rate of climb with full flap extended. Hence the advice to select 20 degrees immediately after full throttle which reduces drag significantly and approximates best lift flap. This technique applies in the POH to the C150, C172 and presumably the C182. Selection of flap up in ten degree stages is not a Cessna manufacturer SOP in the POH. 

While it may sound laudable that a training provider wishes to tailor its training procedures to pilot experience level, the fact is students must be competent to operate the aircraft in accordance to the manufacture's POH if performance figures are to be met. 

It is wrong to send a student solo day or night if he has not been taught to operate the aircraft correctly and safely to the manufacturer's recommendations. That includes a go-around procedure if approaching to land with full flap. Teaching students to land with partial flap invites a higher speed than recommended since there is less drag, and a longer float and possibility of a higher touch down speed. The higher touchdown speed brings with it, its own risks.

Bravo TM, spot on and damn right.   But of course ATSB ain't going to step up to mark and say it is very wrong to teach a homemade, but approved system for a critical flight sequence – the fellah was sick don'tcha know.   Well, that's Avmed back in the spotlight.  

What a cluster of ducks.